World Health Organization — Europe
European Observatory
Edited by:Sagan; Erin Webb; Natasha Azzopardi-Muscat; Isabel de la Mata; Martin McKee; Josep Figueras
2021
Overview
The COVID-19 pandemic represents a health system shock of unprecedented scale. Health systems resilience — defined as the ability to absorb, adapt, and transform to cope with shocks — is needed to ensure sustained performance of the health system functions (governance, financing, resource generation, and service delivery) so that the ultimate health system goals, especially that of improving health of the population, can be achieved. As we have witnessed, few countries could achieve this goal and even fewer could do so in a sustai
ned way — leaving all countries with important lessons to learn. The lessons derived in this study can inform both the ongoing efforts, while countries are still grappling with the pandemic, as well as help ensure these efforts also incorporate a longer-term perspective, thus improving preparedness to any future health system shocks.
While there is no ‘one-size-fits-all’ response that all countries could replicate, the study identifies 20 key strategies, grouped according to the health systems functions, that have been found as enhancing health systems resilience in the face of COVID-19. They have strong interlinkages and do not work in isolation, and this book also considers how the health system operates in the context of other systems, and broader political and governance structures.
The strategies describe how to secure and (re)allocate financing while leaving no one behind. They emphasize the need for more health workers who are fit for the job and well supported. They demonstrate the importance of strong public health systems and safety nets. They show how providers surged capacity and adapted care pathways for both COVID-19 and non-COVID-19 patients. While the relative importance of the various strategies and their configurations will depend on the specific country contexts, governance emerges as the foundation and lever for health system functioning and resilience. It plays a crucial role in enabling all other functions to work in unison to ensure adequately financed and otherwise well-resourced health service delivery to promote improved health.
This study is targeted at policy-makers and has two aims. First, it provides national policy-makers with evidence from other countries to assess their own responses to COVID-19 and incorporate adjustments that are appropriate for their national contexts. To this end the study offers examples of assessment areas for each of the identified strategies that can be used as the first step in national assessments of health systems resilience. Second, the findings and lessons contained in the study enable us to draw experience from the COVID-19 pandemic to begin “building back better” to improve the response to future health systems shocks and hopefully even pre-empt them. This supports the transition from managing the crisis to achieving more resilient health systems and societies.
Executive summary
COVID-19 has created huge challenges. The lessons it has generated on preparing for future pandemics are clear but they are by no means the only learning. All health systems are vulnerable and there are practical steps that all countries can take, not simply to increase the resources available, but to ensure the capacity to mobilize, adapt and use those resources in different shock scenarios. The Health systems resilience during COVID-19: Lessons for building back better study gathers the evidence of how countries have managed (or not managed) to re-engineer what they do, who does what and how, and draws out the implications for future resilience.
The study understands resilience as the ability of the health system to prepare for, manage and learn from a sudden and extreme disturbance. It is about maintaining the performance of core heath system functions. While the focus here is on responding to shock, it is increasingly evident that the ability to transform and evolve will also be critical in meeting long-term structural challenges to health systems.
The evidence the study assembles is rooted in what has happened and what policy makers need to know for the future. It builds on the core health system functions of governance, financing, resource generation and service delivery and organizes its findings around a set of strategies that policy makers can use to strengthen the resilience of their health systems. These strategies and corresponding examples largely draw on the Health System Response Monitor (HSRM), a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, and benefit from the timeliness and accuracy of the content it collected. The examples used to illustrate each strategy offer ways to achieve the strategic objective but are by no means exhaustive.
The different strategies described in this volume do not sit and should not be viewed in isolation from each other — they are complementary and linked, highlighting the interdependency of the health system functions. Each strategy works best when developed in light of the interactions with other health system elements and of national context. It is essential that these interactions are effective if health system functions are to operate in harmony with each other, as a system.
What have we learned from the COVID-19 responses?
Leading and governing the COVID-19 response
Leading and governing the COVID-19 response is central to aligning these elements. It is perhaps the most complex area to unpack, not least because there is no universally agreed concept of health system governance, but also because of its enabling role for all the other health system functions and the various linkages and feedback loops this creates. Further, much of how a pandemic is managed falls outside the control of the health system itself and yet the health system and public health leadership(s) have to find ways to interface with other systems and the wider political context. At the same time, governance supports political leadership to enable the effective mobilization of resources both within and beyond the health system to facilitate an effective national and international response.
Strategy 1
Steering the response through effective political leadership is dependent (amongst other things) on the governance setup and the wider political context and leadership styles. The leaders of health systems have to build a relationship with their non-health counterparts that are context appropriate and utilize the tools they have to influence policy. They also have to take responsibility for steering how health systems are governed. Steps to support effective leadership include:
· Promoting responsiveness, resourcefulness and the capacity to learn in leaders and organizations, including by intelligent use of health data [Strategy 3].
· Assessing the strengths and vulnerabilities of the wider political system and, specifically, mapping the way it uses incentives, allocates resources, distributes powers and regulates their use.
· Framing communication with and across government in light of how the system works [Strategy 7].
· Encouraging consensus-building efforts like cross-parliamentary committees.
· Fostering good governance including transparency, accountability, participation, integrity and policy capacity.
Strategy 2
Delivering a clear and timely COVID-19 response strategy is critical. The strategy needs to be coherent, recognizing the perceived trade-offs between health and the economy and address implementation. Country experience demonstrates the value of:
· Established mechanisms to set up and update emergency response plans.
· Having the facility (at national level) to introduce emergency legislation.
· Setting time limits to emergency powers and/or systematically reviewing civil liberties challenges.
· Appropriate tools and defined pathways which consider proposed policy interventions in light of the national context, societal and stakeholder interests, and make the policy outcomes “acceptable” and implementable.
· A tradition of formal consultation with science and knowledge-brokering expertise to bridge the science policy gap [Strategy 4].
· Transparent communication particularly when explaining a change in direction [Strategy 7].
Strategy 3
Strengthening monitoring, surveillance and early warning systems clearly falls within the remit of the health system but has huge impact in the wider arena and in terms of delivering an effective response strategy [Strategy 2] and accountability [Strategy 6]. COVID-19 exposed weaknesses at the national, EU, and multilateral level that need to be tackled. Measures that will help include:
· Developing strong disease surveillance and monitoring systems.
· Monitoring provision of essential services and access and ‘following’ vulnerable groups (including by ethnicity and underlying conditions).
· Exploiting digital health tools and coordinating mechanisms to support surveillance and monitoring.
· Boosting the ‘one health’ approach and sharing data and expertise across sectors and nationally, regionally and globally.
· Expanding the EU’s capacity to respond to future cross-border threats and WHO’s health systems surveillance powers and response capacity.
Strategy 4
Transferring the best available evidence from research to policy means making sure the science generated by academia can be used by decision makers working under pressure. Some countries had formal mechanisms to broker knowledge, others did not. There is a demonstrable advantage in:
· Facilitating open access to research.
· Signalling the limits of confidence in new research and acknowledging where it proves to be inaccurate.
· Establishing formal (consultation, expert panel, advisory) mechanisms to enable experts to feed into policy.
· Multidisciplinary working with key disciplines (epidemiology, clinical, social care) and population groups (women, minority ethnic groups).
· Making national public health agencies (and their population health perspective) central in assessing the situation and in advising on which strategies to implement.
· Paying careful attention to the transparency, objectivity and independence of expert advice.
· Using intermediaries to help connect research and policy whether:
o independent knowledge-brokers like the European Observatory on Health Systems and Policies;
o international bodies like WHO and the EU; or from
o civil society.
Strategy 5
Coordinating effectively within (horizontally) and across (vertically) levels of government is important whether government is centralized or decentralized. The pandemic showed clearly that both models have merits at particular points in a crisis. In practice:
· Centralization of power can enhance efficiency in a crisis, but more decentralized approaches have the advantage of being territorially sensitive.
· Coordination is key in ensuring equity and policy coherence.
· Horizontal coordination is supported by mechanisms from emergency committees to inter-agency groups and may be easier to achieve where there are established traditions of liaison.
· Vertical coordination can be undermined by competition over power and the regional and local governments’ distinct agendas; it can be facilitated by established formal and informal ways to manage these competing perspectives.
· Clarity on roles and allowing that these roles can change over time support both horizontal and vertical coordination.
· Aligning decision making authority with implementation responsibilities is also key.
Strategy 6
Ensuring transparency, legitimacy and accountability is essential to protecting systems from abuse and in signaling that the system can be trusted. There is, however, a tension between acting fast in response to an emergency and observing normal due processes, which may promote transparency and minimize the risk of abuse. The experience of the pandemic suggests that:
· Relaxing procurement procedures to allow urgent action opens a system to corruption. However, risks can be mitigated by ensuring procurement changes are transparent and by reviewing practice.
· External oversight is important particularly where emergency legislation restrict civil liberties, and can be achieved in a number of ways including by:
o publishing details of response measures and performance indicators;
o sustaining or setting up parliamentary scrutiny;
o establishing dedicated committees or using (innovative) online tools to monitor responses;
o having judicial and civil society initiatives act as scrutineers; and
o encouraging transparency and anticorruption organizations and protecting ‘whistle-blowers’.
Strategy 7
Communicating clearly and transparently with the population and stakeholders is essential in sharing public health messages and explaining requirements. It also creates trust which in turn promotes compliance. Countries have found that:
· Well-presented data and participatory approaches to data sharing can have a high impact but often are not prioritized.
· Using a variety of channels (broadcast, print press) increases the reach of public health messages, while social media accesses harder-to-reach audiences.
· Targeting specific population groups (the young, the vulnerable, those who don’t speak the country’s official language) with tailored campaigns is effective in a way that one-size-fits-all messages are not.
· Multiple channels and messages can create inconsistency and confusion; coordinating communication across channels and actors through a national communication strategy ensures consistency but is not easy to achieve.
· There is a huge challenge from (an “infodemic” of) misinformation particularly on social media and a corresponding need to fact check and moderate.
Strategy 8
Involving non-governmental stakeholders including the health workforce, civil society and communities strengthens emergency responses. Countries have increased roles for a mix of ‘non-state actors’ over the course of the pandemic and used them in different settings. Their experience suggests that:
· Professional bodies and medical associations support mobilization of resources and transmission of key information such as clinical evidence.
· Engaging with non-state actors helps policy makers to formulate appropriate and acceptable responses.
· Involving civil society in information sharing and in providing services like testing, taps into the trust they have established and boosts capacity.
· Participation also develops trust, helps reach marginalized populations and increases uptake of public health measures.
· The private sector can usefully contribute to multi-stakeholder approaches to resource mobilization.
· Consulting unions and employers helps improve the design of government support packages.
· Pre-existing structures and tools and new coordinating structures support the alignment of non-state actor efforts.
Strategy 9
Coordinating the COVID-19 response beyond national borders is critical to long-term success against the pandemic. At the outset there were tensions between the international perspective and a ‘home nation first’ position, some of which persist, but solidarity has strengthened with time. It is observable that:
· Countries who had prior, direct experience of similar pandemics responded more effectively and have lessons to share.
· The pooling of scientific expertise and knowledge sharing confers real advantage.
· Commitments to international cooperation do not automatically translate into willingness to coordinate health emergency responses although over time there was more support for cross-country initiatives.
· Cross country collaboration is nonetheless worthwhile both in terms of preparedness and response (capacity sharing, joint procurement).
· There is scope to strengthen international preparedness for future threats whether through EU level action or by enhancing the role of WHO in global health governance.
· The European Commission has already made a series of proposals to strengthen the EU’s capacity to respond under the general framework of the European Health Union, while the Pan-European Commission on Health and Sustainable Development made a series of recommendations targeted at the pan-European and global levels.
The strategies which fall into the governance domain overlap and interact with each other. Monitoring and translating evidence into policy [Strategies 3 and 4] for example, help political leaders to steer responses better and with planning a coherent response [Strategies 1 and 2] but they also enable transparency and accountability [Strategy 6]. By the same token, good communication [Strategy 7] is fundamental to accountability but also to cross governmental coordination and to engagement with non-governmental stakeholders [Strategies 5 and 8]. Policy makers can achieve most where they consider the links between strategies and combine different approaches to fit the national context.
Financing COVID-19 services
Financing services for COVID-19 is the second functional area that the study explores. The pandemic disrupted all of financing, from the availability of sufficient and predictable levels of funding, to the demands made on funds (which had to cover intensive care, new materials and equipment), to the flow of funds through the system (where health service providers were affected by dramatic changes in the services needed). It is essential that health systems can allocate resources so they are available in the right places and in good time to deliver quality health services to the whole population including those who cannot afford to pay, without people experiencing financial hardship.
Strategy 10
Ensuring sufficient and stable funds to meet needs is easier for countries with well-funded health systems which can absorb unexpected costs but all countries have managed to mobilize additional monies in the crisis. It has become evident that:
· Mechanisms to draw down financial reserves and/or to undertake public borrowing allow countries to meet unpredictable needs.
· Having an earmarked reserve of funding for health makes it easier to quickly cover financing gaps.
· Public financial management rules can create blocks to flexibility, with line budgeting making it particularly difficult to reallocate public funds to the health system.
· Countercyclical health financing mechanisms are an important tool that shield health systems from the effects of a sudden rise in unemployment (caused by the pandemic).
· Borrowing and mechanisms such as bonds and debt service relief can help bring in funds.
· International initiatives can also prove useful as with the dedicated recovery fund for EU Member States or the support provided by the European Commission, the UN, and the World Bank.
Strategy 11
Adapting purchasing, procurement and payment systems to meet changing needs and balance economic incentives is critical in flowing funds through the health system appropriately. Countries have had to reengineer financing to: deliver additional services; to protect core providers from the financial disruption; and to make procurement as efficient as possible. Countries have found that:
· The ability to change or restructure payment systems and channels is crucial in:
o getting funds to providers (institutions and professionals) to offset income losses; and
o incentivizing the provision of new services.
· Flexibility in changing payment systems to provide the ability to replace activity-based payments with budgets or flat-rate compensation; introducing new fee-for-service payments; and reimbursing extra capital spending can all prove effective in meeting COVID-19 financing needs, including compensating providers for income loss.
· Changes in payment systems can ensure services to vulnerable populations and/or support innovative models of care.
· Incentives for extra services need to be revaluated to ‘remove’ those which prove ineffective.
· Centralizing procurement (including at EU level) can help meet urgent needs more efficiently.
· More flexible approaches to procurement, while often essential, need to be monitored for potential abuses that need to be addressed [Strategy 6].
Strategy 12
Supporting universal health coverage and reducing barriers to services are all about access and, in the case of COVID, about how to meet new health needs while sustaining essential services. Countries have had to expand or adjust the range of services, the share of costs and the population groups covered to protect people and particularly the vulnerable and to ensure access. Their experiences show that:
· Offering COVID-19-related services to everybody and at no cost facilitates uptake (although populations who are normally excluded can still be hard to reach).
· Taking active steps to reach people who are not otherwise eligible for health coverage (undocumented migrants, the unemployed) is critical because of the high risk of infection these groups face and because of the risk that poses to wider public health.
· Removing user charges can be key not just for COVID-19 services but in maintaining access to routine services during economic shocks.
· Fast-track health technology assessment (HTA) helped address COVID-19 but decisions need to be reviewed to ensure effectiveness.
Mobilizing and supporting the health workforce
Mobilizing and supporting the health workforce is the third functional area that the study focuses on. All countries, whatever their starting point in terms of staffing/shortages, geographical inequities and skill mix, have had to respond to surges in demand and extreme pressures on workers. Pre-existing staff shortages and unevenness in staff distribution make it more difficult to scale up. They have had to adapt at extraordinary speed to deliver acute care and to cover vaccination programmes while at the same time trying to ensure that other essential and non-essential services continue. Again, this has meant systems changing and adapting.
Strategy 13
Ensuring an adequate health workforce by scaling-up existing capacity and recruiting additional health workers is one response or rather one set of responses to the burdens of the pandemic. Countries have sought to increase the capacity of the existing workers and to bring in additional health workers. There has been important learning, including that:
· Data on health workforce availability and skill profiles is needed to inform actions to surge capacity.
· Increasing the workload of existing staff by extending hours, cancelling leave, and suspending employment limitations increases capacity but has risks, including burn out [Strategy 15].
· Adapting staff roles, shifting tasks within teams and redeployment helps but requires training and support [Strategy 14].
· Mobilising medical and nursing students, inactive or retired health personnel, private sector workers, and volunteers can increase capacity but requires system change.
· Legislation and regulation need to be adapted to accommodate new recruitment and to make legal provision for insurance, pensions and so on.
· Coordinating national policies and local responses from employers and managers is needed for implementation.
Strategy 14
Implementing flexible and effective approaches to using the workforce means changing what individual staff do and the way tasks and roles are combined so that new demands can be met. The efforts in countries indicate that:
· Modifying work practices, adjusting skill-mix, and redeploying people support the optimal use of staff in hospital and outpatient settings.
· Having well-developed task shifting arrangements in place makes change easier.
· Involving professional associations supports new working practices.
· Providing adequate (re)training is important and should reflect the health worker needs.
· Changing what staff do also requires that suitable medical indemnity is put in place.
· Delegating tasks (such as tracing, testing or vaccination) to non-medical personnel or volunteers allows health workers to concentrate on more specialist services.
· Changes need to be reviewed but have demonstrated the scope for updating established practices and innovation long term.
Strategy 15
Ensuring physical, mental health and financial support for health workers is important in sustaining commitment and in helping to minimize absenteeism and burn out. Countries struggled to provide personal protective equipment (PPE) and train staff, particularly at the outset, and the financial costs of providing support continues to be a challenge [Strategies 10 and 11]. Nonetheless, there is good evidence that:
· Providing PPE, regular testing, and training do protect physical health and also signal that workforce wellbeing is a priority
· Offering remote counselling and other online support also supports staff mental health, helps people function under pressure, and indicates commitment to them.
· Addressing practical needs is also essential for staff to be able to continue to work. Making childcare available when schools closed and helping with accommodation and transport enables workers to continue to do their jobs.
· Financial support also has a role in rewarding additional work and in recognizing health workers.
· Failing to tackle physical, mental health and financial stresses has negative impacts on motivation and on staff retention.
Strengthening public health interventions
Public health is the discipline that is best equipped to deal with pandemics, with its roots in the management of infectious diseases. Its main task is to protect population health as a whole and this requires making strategic choices about which services, populations, and vulnerabilities to prioritize as well as strong communication and outreach mechanisms. It is thus ideally placed (in theory) to shape responses to health emergencies — with one foot in science and one in politics. Public health has however played very different roles in different countries with varying degrees of impact. Strengthening public health is an important way of fostering resilience to future pandemics.
Strategy 16
Implementing appropriate non-pharmaceutical interventions and Find, Test, Trace, Isolate and Support (FTTIS) services to control or mitigate transmission relates very specifically to infectious disease outbreaks but touches too on fundamental public health skills. It is evident that:
· Implementation of (non-pharmaceutical) measures (face masks, physical distancing, vaccine ‘passports’) varied over time in response to emerging evidence, which required updateable structures and processes as well as effective communication.
· Having strong (pre-existing) public health and primary care systems conferred an advantage particularly where there was a tradition of public health–primary care– community linkages.
· Innovative digital technologies including contact and symptom tracking apps had only mixed value and also faced challenges around acceptability [Strategy 6].
· Public health needs to secure public acceptance of interventions, including by:
o considering their unintended impacts and civil liberties connotations;
o communicating clearly and with an understanding of public perceptions; and
o taking particular care in explaining policy changes.
· Consulting non-government stakeholders in civil society and communities has value [Strategy 8] with public health — a logical entry point for engagement.
· Income and social support (adequate sick pay, benefits) are critical if isolation policies are to be workable and in protecting people who lose their jobs or who live precariously.
Strategy 17
Implementing effective COVID-19 vaccination programmes is the route out of the pandemic and another traditional area of public health expertise. In this instance, countries have had to contend with international, national, and local dimensions. They have found that:
· Mechanisms to coordinate efforts across countries, including COVAX led by the WHO and the EU’s Vaccine Strategy, are a huge asset in vaccine development.
· Multilateral action on procurement and distribution is also an advantage, particularly for smaller countries, although putting models in place from scratch is complex [Strategy 9].
· Investment from public sources played a major role in vaccine development but there needs to be some reappraisal to better balance the benefits accruing to the public and private sectors.
· Careful planning and monitoring are essential to provide adequate supplies, venues and workforce for effective purchasing, distribution and dispensing of vaccines.
· Established mechanisms for creating plans at the national level allowed countries to deliver under pressure and to maintain equity across regions.
· The legislative and regulatory flexibility to adapt the use of health workers and infrastructure facilitated the rapid roll out of vaccination programmes.
· National monitoring systems and real-time data is necessary to manage well [Strategy 3].
· Communication campaigns are also a crucial part of tackling misinformation and vaccine hesitancy [Strategy 7]. A focus on community engagement helped vaccine uptake [Strategy 8].
Strategy 18
Maintaining routine public health services including screening and vaccination proved difficult as resources were diverted to tackle COVID and facilities closed. Routine services were also hampered by public reluctance to seek care both out of fear of infection and a reluctance to ‘trouble the health system’ at a time of crisis. The experience in countries suggests that:
· There has been a pattern of chronic under investment in public health across Europe.
· Routine services are more difficult to sustain during a crisis if the system is already under resourced.
· Taking a strategic approach to priority setting for ‘non-emergency’ public health services can ensure the best use of the remaining health system capacity and protect access but requires adequate information and decision-making capacity.
· Systems where public health and primary health care were closely linked were better able to reassign roles and maintain services [Strategy 20].
· Established multidisciplinary approaches to public health and existing links to mental health and social care services also facilitated comprehensive responses.
Transforming delivery of health services to address COVID-19 and other needs
Transforming delivery of health services was essential in providing care for patients with COVID-19. The study looks at how systems coped and at the wider lessons for resilience, particularly in terms of surges in demand for intensive care beds and in maintaining essential (and non-essential) services. Countries have focused on these two mechanisms and the workforce implications.
Strategy 19
Scaling-up, repurposing and (re)distributing existing capacity to cope with sudden surges in COVID-19 demand means making capacities available at the right points in time and in the right places. It is crucial and depends on the ability to coordinate all relevant elements. Countries have found that:
· Systems with routinely high bed occupancy rates had little spare capacity and faced additional pressures in scaling up.
· Hospital capacity can be increased fairly rapidly by repurposing existing beds, using beds in the private sector or military settings, or transferring patients between facilities, regions, and countries.
· Increasing infrastructure must happen in tandem with increased workforce capacity. New and temporary facilities were hampered by a lack of skilled staff.
· Beds can only be fully operational if material capacity is sustained which means clear coordination and well-defined responsibility for the supply chain.
· The ability to manage resources effectively was dependent on the availability of real-time data. This was easier where there were already information systems in place.
· The access to appropriate financing and procurement mechanisms also helped sourcing materials.
· Inefficiencies can arise when the focus on hospital beds diverts attention from primary care and skews treatment modalities so that patients who could have been treated in ambulatory care are admitted.
Strategy 20
Adapting or transforming service delivery by implementing alternative and flexible patient care pathways and interventions and recognizing the key role of primary health care was a way of dealing with the treatment of COVID patients and maintaining essential non-COVID care. Countries’ experiences show that:
· Creating dual delivery care pathways to separate COVID and non-COVID patients protects patients and staff.
· An existing ability to coordinate across levels of care and care settings helps in adapting care pathways.
· Having mechanisms in place to determine and update guidelines and to communicate the information to clinicians was critical in ensuring best management of COVID-19 cases. The use of professional bodies, online training, feedback, and compliance systems all supported this.
· The ability to adjust and update decisions on provision of essential services in light of the epidemiological situation was also crucial in revising policy on non-urgent care as disease severity fluctuated.
· Primary health care (PHC) has a set of key roles to play in managing COVID-19 outside hospitals, providing essential care, and sustaining public health services [Strategy 18].
· Using digital health tools (remote consultations, remote monitoring) increases PHC capacity but may well require adjustments in legal and financial frameworks.
· Inadequate support for vulnerable groups was widespread and was a failing in its own right and a threat to the effectiveness of the overall response.
· Mental health care needs require careful monitoring due to the increased burden across the population.
How can COVID-19 inform health systems ‘building back better’?
COVID-19 has thrown up extraordinary examples of resilience: the health workforce has absorbed phenomenal pressures and continued to function; new ways of working have been introduced, new facilities opened, new types of services delivered; several COVID-19 vaccines were developed and approved; and governments have found the money for health care and to protect their populations from the worst of the pandemic’s economic effects. Nevertheless, all governments and all countries are aware of the very real failures: to sustain essential services; to protect health care workers; and to safeguard public health and, foremost, save lives. Health systems, however well they managed during the crisis, were woefully underprepared and this points to, perhaps the most frustrating of all failings, the failure to learn from past crises. It was made abundantly clear during the financial crisis of 2008 that health systems, health, and wealth are inextricably linked to each other and that underinvesting in health systems has significant consequences not just for health but also for the economy itself and, ultimately, for our wellbeing. The COVID-19 pandemic offers lessons for how — this time — countries might build back better.
There is a need to invest more in health systems and moreover for that investment to be appropriate. This implies putting funding into neglected areas and managing that funding efficiently. Areas that are critical to building back better and which require well managed investment include:
· Surveillance and monitoring systems that will allow health systems to respond and be better managed.
· Primary health care which is often the most appropriate and cost-effective setting for care.
· Public health which is best placed to handling threats of infectious and chronic diseases, including by influencing socioeconomic determinants of health and providing outreach to excluded communities.
· Skills and initiatives to promote better ways of working for individuals and teams, as well as across levels of health and social care.
· Remote health tools that complement more conventional patient clinician contact.
· New care pathways that draw on the investments in primary care, skills, and digital tools, and can be flexibly adapted in an emergency.
There is also a pressing need to invest in governance and the complex mix of capacities required to make health systems resilient in crisis and in normal times. Again, investments need to be appropriate and to work across three levels of governance: within health systems; with society more widely; and lastly, in terms of the international community. There is an opportunity now to: ‘
· Reimagine health systems governance, accounting for various contexts and the new multi-level and multi-stakeholder approaches that have surfaced during this pandemic.
· Ensure governance systems are more flexible, which allows changes and encourages innovation in an emergency, but which also insists on following the due process to protect health systems from abuse and a post hoc review.
· Develop stronger links beyond health systems, making health part of the wider discussion and planning of the economy and of social security.
· Improve two-way communications to build trust including through closer health system engagement with social networks and communities, with civil society, and with other stakeholders.
· Incorporate a clear international perspective that links governments with each other and with international bodies and which considers how to develop and distribute resources equitably.
· Strengthen European and global health governance, with adequate financing and enforcement mechanisms, to guard against repeating the mistakes of this crisis.
None of these investments will be possible without the political will to prioritize health. People are acutely aware of the role of health systems in the pandemic. Political leaders now need to make resilient health systems central to their thinking about the future. They need to commit to health system investment and innovation, not just to protect against future health threats or even as a way of dealing with long-term structural challenges, but as a pillar of social solidarity and economic prosperity and as a key route to societal wellbeing.
How can COVID-19 inform health systems ‘building back better’?
COVID-19 has thrown up extraordinary examples of resilience: the health workforce has absorbed phenomenal pressures and continued to function; new ways of working have been introduced, new facilities opened, new types of services delivered; several COVID-19 vaccines were developed and approved; and governments have found the money for health care and to protect their populations from the worst of the pandemic’s economic effects. Nevertheless, all governments and all countries are aware of the very real failures: to sustain essential services; to protect health care workers; and to safeguard public health and, foremost, save lives. Health systems, however well they managed during the crisis, were woefully underprepared and this points to, perhaps the most frustrating of all failings, the failure to learn from past crises. It was made abundantly clear during the financial crisis of 2008 that health systems, health, and wealth are inextricably linked to each other and that underinvesting in health systems has significant consequences not just for health but also for the economy itself and, ultimately, for our wellbeing. The COVID-19 pandemic offers lessons for how — this time — countries might build back better.
There is a need to invest more in health systems and moreover for that investment to be appropriate. This implies putting funding into neglected areas and managing that funding efficiently. ]
Areas that are critical to building back better and which require well managed investment include:
· Surveillance and monitoring systems that will allow health systems to respond and be better managed.
· Primary health care which is often the most appropriate and cost-effective setting for care.
· Public health which is best placed to handling threats of infectious and chronic diseases, including by influencing socioeconomic determinants of health and providing outreach to excluded communities.
· Skills and initiatives to promote better ways of working for individuals and teams, as well as across levels of health and social care.
· Remote health tools that complement more conventional patient clinician contact.
· New care pathways that draw on the investments in primary care, skills, and digital tools, and can be flexibly adapted in an emergency.
There is also a pressing need to invest in governance and the complex mix of capacities required to make health systems resilient in crisis and in normal times. Again, investments need to be appropriate and to work across three levels of governance: within health systems; with society more widely; and lastly, in terms of the international community.
There is an opportunity now to: ‘
· Reimagine health systems governance, accounting for various contexts and the new multi-level and multi-stakeholder approaches that have surfaced during this pandemic.
· Ensure governance systems are more flexible, which allows changes and encourages innovation in an emergency, but which also insists on following the due process to protect health systems from abuse and a post hoc review.
· Develop stronger links beyond health systems, making health part of the wider discussion and planning of the economy and of social security.
· Improve two-way communications to build trust including through closer health system engagement with social networks and communities, with civil society, and with other stakeholders.
· Incorporate a clear international perspective that links governments with each other and with international bodies and which considers how to develop and distribute resources equitably.
· Strengthen European and global health governance, with adequate financing and enforcement mechanisms, to guard against repeating the mistakes of this crisis.
None of these investments will be possible without the political will to prioritize health. People are acutely aware of the role of health systems in the pandemic. Political leaders now need to make resilient health systems central to their thinking about the future. They need to commit to health system investment and innovation, not just to protect against future health threats or even as a way of dealing with long-term structural challenges, but as a pillar of social solidarity and economic prosperity and as a key route to societal wellbeing.
