Governance strategies for building health system resilience
Euro Health
Hans Kluge,
Natasha Azzopardi Muscat,
Dorit Nitzan,
Josep Figueras
Matthias Wismar
2021, Vol.7, n.1
Governance is about making and implementing collective decisions.
It is therefore vitally important to health policy and implementation and is a pivotal, yet often underestimated, enabler for leading a health system in times of emergencies, preventing them from becoming a crisis.
The importance of effective governance for determining health system performance and resilience has been emphatically highlighted by the COVID-19 pandemic.
Across Europe, governance mechanisms have provided a foundation for countries to rapidly mobilise and deploy financial and human resources to where they were most needed, to reconfigure service delivery, to implement mass test-trace-isolate-quarantine operations and to implement evidence-informed policies.
Yet, in the face of unprecedented challenges, key gaps in governance for emergencies have been revealed and have undermined the effectiveness of national and international responses.
A central challenge now is to learn from all of these experiences, as this evidence will be critical for building stronger health systems to support the post-pandemic recovery and for renewing and strengthening health emergency governance mechanisms to be better prepared for future emergencies.
In support of this analysis, this special issue of Eurohealth brings together a collection of articles that examine different elements of governing the COVID-19 pandemic in the countries of the WHO European Region.
These articles shed light on the achievements and progress made despite many unknowns during the early stages of the pandemic, and the challenges faced over a long-term emergency.
In doing so, the issue draws out clear lessons for how to advance positive changes in support of developing stronger national and global governance structures that can better respond to health emergencies.
A first important lesson that emerges is that more resilient responses have been launched by countries that had good governance structures, underpinned by strong state capacity, in place prior to the pandemic [see Sagan et al., in this issue].
Nevertheless, while pre-existing governance strategies and mechanisms have supported timely and effective responses, more adaptive approaches to governance during the crisis have also been required.
These have encompassed setting out clear and timely COVID-19 response strategies, developing novel public-private partnerships, seeking engagement with communities, and harnessing improved coordination across sectors and across levels — from the local to the global.
Many of the governance elements identified by Sagan et al., as being critical for building a resilient response are further highlighted throughout the issue.
Rajan and co-authors, for example, demonstrate the importance of bringing civil society’s perspectives, insights, and experiences into COVID-19 decision-making, but suggest this has not been achieved in a systematic way in many countries.
The authors therefore propose investing in developing participatory mechanisms to improve social participation in the future, which will help drive forward more equitable health system reforms.
Tille et al., meanwhile show how rapidly developed, new public-private partnerships have enabled some countries to gain faster access to and more stable supplies of products and services, ranging from personal protective equipment to the development and deployment of COVID-19 vaccines.
Learning from these pandemic experiences provides a unique opportunity to re-shape governance frameworks for public-private partnerships in the future, to help improve equity, fairness and transparency.
Governance, inevitably, cannot be discussed without reflecting on the role of leadership.
Capable and effective leaders that engaged with scientists and took evidence-informed decisions have been fundamental enablers of resilient pandemic responses [see Sagan et al., in this issue].
However, in some countries, orientations other than health short-sightedly and repeatedly became the foundation of decision making at the expense of effective COVID-19 strategies.
It is therefore argued by Nathan and co-authors that public health leadership in the future should be strengthened — by investing in public health institutions, breaking down internal silos in health sectors and building leadership capacity across the public health workforce — to empower a broader range of health actors to inform health policy to see us through some potentially bigger challenges ahead.
Leadership at many levels has also played a critical role in strengthening the health workforce with regards to creating surge capacity, protecting the health and well-being of health workers, and the rollout of vaccination programmes [see Buchan et al., in this issue].
Here, national and local policymakers, professional associations and employers of health workers, have worked together effectively, often breaking up sclerotic governance structures which have hampered past health workforce development and reform.
While the pandemic has proved immensely challenging for health and care workers, building on progress and momentum seen during the pandemic may hold the potential to help develop a more resilient workforce in the future.
As well as strengthening national governance structures, the pandemic has highlighted the need to revitalise the global health governance architecture, as discussions on the International Health Regulations (IHR) (2005) and a pandemic treaty demonstrates. Countries cannot tackle global threats in isolation; they need to intensify their collaboration.
This includes the timely sharing of data and financial and technical support. McKee and Greer in this issue go further in their analysis, arguing that more effective global collaboration on public health requires that countries pool some of their health-related sovereignty and strengthen WHO as the custodian of such a treaty.
This special issue also documents how WHO is supporting Member States in strengthening their pandemic governance.
One example is the WHO’s Health Emergencies Programme (WHE) created in 2016 [see Smallwood et al., in this issue].
It demonstrates the important role of multinational governance in responding to the pandemic.
Learning from pandemics and building stronger global governance structures is possible as advances following the swine flu in 2009 have demonstrated, with the resulting Pandemic Influenza Preparedness Framework strengthening capacity to identify the virus though the activation of a network of laboratories and experts in a timely manner [see Nitzan et al., in this issue].
From the lessons learned through the WHO’s work in the Region, it also becomes clear that universal health coverage is a precondition for the overall whole-of-society and whole-of-government preparedness.
The pandemic has also amplified the need to take action to address the social and economic determinants of health and to develop pandemic preparedness and post-COVID recovery plans that link policy actions across sectors [see the article by Permanand and Azzopardi Muscat].
It is clear that effective governance strategies are fundamental for building health system resilience.
The next emergency, whether it is the economic fall out of the pandemic, an environmental, cyber or refugee and migration crisis, or another virus, is just around the corner.
We must not wait to prepare for it, but should rather draw on the lessons learned from this pandemic to help strengthen the governance of our health systems now to ensure better resilience and performance.
Hans Kluge,
WHO Regional Director for Europe
Natasha Azzopardi Muscat,
Director, Division of Country Health Policies and Systems, WHO Regional Office for Europe
Dorit Nitzan,
Regional Emergency Director, WHO Regional Office for Europe
Josep Figueras,
Director, European Observatory on Health Systems and Policies
Matthias Wismar, Programme Manager, European Observatory on Health Systems and Policies
Cite this as: Eurohealth 2021; 27(1).
Cite this as: Eurohealth 2021; 27(1).
Originally published at
COVID-19 and the opportunity to strengthen health system governance (Eurohealth) (who.int)
