Global Health Leaders Discuss Health System Strengthening to Prevent, Prepare, and Respond to Future Pandemics

On December 8, SDSN and the Center for Sustainable Development at Columbia University (CSD) hosted the final webinar of a three-part series to further discussions on the Lancet COVID-19 Commission’s findings and recommendations presented in their final report, The Lancet Commission on lessons for the future from COVID-19.

The Lancet COVID-19 Commission, which ran from July 2020 to October 2022, was an interdisciplinary initiative encompassing the health sciences, business, finance and public policy. From 2020 - 2022, the Commissioners and Task Forces focused on four main themes: (1) recommendations on how to best suppress the epidemic; (2) addressing the humanitarian crises arising from the pandemic; (3) addressing the financial and economic crises resulting from the pandemic; and (4) rebuilding an inclusive, fair, and sustainable world.

The webinar on Health Systems Strengthening presented opportunities for global health leaders to discuss response to the COVID-19 pandemic in their regions and how health systems can be strengthened to prevent, prepare, and respond to future pandemics and achieve our other global health goals, particularly Sustainable Development Goal 3.8 to achieve universal health coverage (UHC).

Prof. Jeffrey Sachs, Chair of the Lancet COVID-19 Commission, began the webinar by presenting the Commission’s conclusion that functioning health systems – both in terms of clinical response and public health services – are essential for effective responses to pandemics and other health challenges in all parts of the world. He reviewed the key recommendations of the final report of the Commission regarding health system strengthening:

1. Countries should strengthen national health systems on the foundations of public health and universal health coverage grounded in human rights and gender equality.
2. Each country should determine and expand national pandemic preparedness plans to prevent and respond to newly emerging infectious diseases. Many countries were ill-prepared for SARS-CoV-2.
3. A new Global Health Fund, closely aligned with WHO, should be established that combines and expands on the operations of several existing health funds to support health systems in low- and middle-income countries.

Prof. Sachs provided a quick summary of the health systems landscape, highlighting the stark contrast in life expectancy between the poor countries of sub-Saharan Africa (life expectancy in the mid-50s) and the high-income countries of Europe and East Asia (life expectancy in the mid-80s). He then illustrated the major financing issues of health systems in low-income countries, giving the example of budget outlays for health in a poor country. He argued that just one-tenth of 1% of the GDP of the high-income countries, or $60 billion USD per year, could raise life expectancy and the functionality of health systems in low-income countries.

Dr. Andrea Ammon, Director of the European CDC, focused on the lessons learned from the last 3 years of the pandemic from the experience of the high-income countries in the European Union. To better address emerging infectious diseases in the future, she argued that regional organizations must develop multi-sectoral and multidisciplinary preparedness plans that are transferrable between different health threats. She stated that one of the region’s main investments in coming years will be in the resilience and modernization of surveillance systems, modeling, and forecasting for emerging infectious diseases.

Dr. Ammon provided her specific learnings about national preparedness plans, emphasizing the need for country coordination, especially since many people who had to cross borders for work faced significant difficulties when countries independently restricted movement between countries and provided little notice. She called for local level strengthening of primary and public health care, as these services bear the brunt of surges, and for hospital stockpiles to be well-maintained with necessary equipment, PPE, and medicines. Dr. Ammon stressed the importance of community engagement by health institutions during the different phases of the pandemic, recognizing that over time, issues of communication led to declining community adherence to public health policies and recommendations. Finally, Dr. Ammon discussed efforts of the European CDC to intensify global cooperation based in solidarity and equity and built on trust and consistency, including the global network of CDCs to share best practices and real-time learnings.

Dr. James Fitzgerald, Director of Health Systems and Services Department at the Pan-American Health Organization (PAHO), reflected on some of the main challenges and opportunities that the region of the Americas is facing to introduce substantive and transformational health systems underpinned by equity, solidarity, and the right to health. He celebrated the global and intersectoral composition of theLancet Commission’s recommendations. Dr. Fitzgerald highlighted pre-pandemic examples of improved service coverage and reductions in the incidence of catastrophic out-of-pocket health spending in the region of the Americas in 2017 and described the subsequent reversal of the regions’ steady progress towards the achievement of UHC due to the COVID-19 pandemic. He acknowledged the continuing inequalities of access to service coverage, especially for vulnerable populations, and the low priority that has been given to investments in primary care. Dr. Fitzgerald estimated that approximately 600,000 additional health professionals will be needed in the region to recover lost public health gains and retake the path to achieve health-related SDGs by 2030.

Dr. Fitzgerald stated that the COVID-19 pandemic has exposed and exacerbated structural weaknesses of health systems, and that prevailing structural inequities, social exclusion, the lack of adequate financing, and health system segmentation and fragmentation provided poor systems performance during the crisis. He highlighted that in December 2021, 93% of the 28 countries in the region reported disruptions of at least one essential health service. There were shortages and inequalities in access to essential medicines and technologies in the region, especially due to the dependence of Latin America and the Caribbean on imports of health technologies such as vaccines and therapeutics.

Dr. Fitzgerald concluded that the region of the Americas urgently needs to reverse the socioeconomic and health setbacks of the COVID-19 pandemic and he reaffirmed the importance of UHC based on primary health care to ensure the capacity to prepare for and respond effectively to crises, maintain core functions when a crisis hits, and reorganize and transform if conditions require. He presented the new PAHO strategy to promote systemic transformation alongside renewed efforts to increase research and innovation for vaccines, medicines, and other health technologies; strengthen regulatory systems; and promote greater regional-wide integration and solidarity.

Ms. Pauline Irungu, Global Policy and Advocacy Advisor of PATH described the course of COVID-19 in the African context, highlighting the weaknesses of primary health and tertiary care systems; the difficulties of accessing essential medical products, including PPE and masks; and inequities of global vaccine distribution. Ms. Irungu stated that although the African continent experienced low reported death rates compared to other world regions, the impacts of COVID-19 on health systems, social development, and economies remain enormous. There have been reductions in essential health services for reproductive and maternal health, non-communicable diseases, and vaccination services for children. Diversion of finance from essential health services to emergency response exacerbated the lack of funding for primary health care.

Ms. Irungu outlined the lessons of the African experience of COVID-19, emphasizing the need to strengthen preventive services and health promotion efforts, particularly through the professionalization and formalization of health services that are currently run by community health volunteers. She added that governments need to engage strategic partners from communities, the private sector, and the infrastructure development sector, among others, to treat health as an efficient investment that delivers for the whole economy. Health system investments must be characterized by donor alignment and should invest in country systems, along the lines of the African Development Bank strategy for 2030.

Ms. Irungu stated that it is important to build strong social health insurance systems to protect people from catastrophic out-of-pocket health expenditures and to build investments for the capacity and retention of human resources for health on the African continent. She argued that regional institutions in the African continent need to be strengthened and work in coordination across countries and regions to share resources. Finally, Ms. Irungu noted the importance of accelerating Africa’s manufacturing capacity for vaccines and other health commodities and building stronger data systems to show the reality on the ground and provide the basis for regional cooperation. She pointed out that civil society did a great job of building trust with communities and facilitating conversation between communities and governments, which is essential to strengthen health systems for pandemics.

Mr. Martin Taylor, Director of Health Systems and Services for the WHO Western Pacific Region, described the response of the diverse Western Pacific Region (WPR) to COVID-19, mentioning that their response was broadly guided by the third iteration of the Asia-Pacific Strategy for Emerging Diseases and Public Health Emergencies. He highlighted a few areas of reflection on strengthening systems to achieve UHC.

First, Mr. Taylor pointed out the necessity of adequate supplies of basic health equipment, including oxygen, PCR testing, and laboratory capacity, as well as adequate operational management to ensure that countries refer patients to the correct level of care to maximize the efficiency of limited space in hospital intensive care units. Mr. Taylor praised national regulatory authorities that made sure that new vaccines were available, licensed, regulated, and available in countries as soon as possible, and legislators who worked to update public health emergency legislation for the digital era. While there were some innovative efforts by countries in the WPR region to streamline public finance to make health services available at no cost, catastrophic health expenditure remains a problem in the region.

Mr. Taylor emphasized the importance of community engagement and risk communication, especially for vulnerable populations, and gave examples of the success of engagement for higher COVID vaccination rates and antenatal care. He also addressed the positive takeaways from the pandemic for coordination among Ministries of Finance, Internal Affairs, and local governments, among others to achieve common agendas. Mr. Taylor described the challenges for the future, including prioritizing vulnerable populations for public health interventions, supporting the health workforce by providing living wages and encouraging social value, and long-term financial investments in primary health care to achieve the Sustainable Development Goals. He also mentioned the necessity of real-time data, surveillance, and forecasting to help leaders and planners make daily critical decisions, and efforts to link public health and curative functions. He concluded that fundamental challenges to achieve UHC remain, but that there is a lot of positive development in health system strengthening to build on from the pandemic era.

Prof. Sachs highlighted the commonalities among the speakers’ presentations, particularly the themes of finance for catastrophic health costs, primary health care systems, and decent health workforce compensation. He asked the speakers to reflect on the extent of real regional cooperation and strategy. Prof. Sachs then how leaders and organizations can build public communication and facilitate trust.

Dr. Ammon responded first, highlighting the joint procurement of vaccines in the EU to benefit small countries in the region as one example of effective regional cooperation, acknowledging that improvements are also needed on the issue of border closures. She emphasized that public messaging must be understandable at the community level, and that political communication is key for better public adherence to public health measures. Ms. Irungu followed, saying that the Africa CDC provided a strong example of regional cooperation, including the establishment of the African Vaccine Acquisition Task Team, regular dialogues hosted by the CDC to share lessons learned, a conference on public health in Africa, and the Africa Medicines Agency to strengthen regulatory systems. She added that public communication was not only driven by political leaders, but also by technical leaders from the Ministries of Health who had the right information, strengthened by new methods of sharing messages with communities (e.g., #AsktheDG with the Director-General of Health in Kenya).

Mr. Taylor stated that although the WPR region exhibited strong cooperation at the clinical, scientific, and technical level, countries also imposed travel restrictions and import/export restrictions quickly and in isolation. He highlighted that regarding public communication, it is important to listen to what is shared on social media and elsewhere to understand and segment the populations and their needs, and to determine which groups have the strongest influence. Dr. Fitzgerald added the positive experiences of cooperation through PAHO, especially digital educational sharing of information. He lamented the inequity of vaccine allocation efforts that prioritized bilateral agreements over commitments to COVAX and mentioned that the biggest concern for trust is the lack of confidence in vaccines, which has multi-faceted impacts for core public health functions.

Ms. Juliana Bartels, a member of the Secretariat of the Lancet COVID-19 Commission, posed a question from the audience about the issue of high-income countries poaching health workers from low-income countries, and the state of training and education for human resources for health. Dr. Ammon responded that training is not the issue for health workers; low salaries and decent living conditions are the reasons for health worker migration. She highlighted the work of the European CDC with the Africa CDC for public health workforce training in Africa.

Ms. Bartels acknowledged the speakers’ previous discussion of the importance of accurate, real-time data and modeling on infections, burden, and deaths during the COVID-19 pandemic. She asked what the current strategies are to collect important data and make sure that they are used to inform policy and public health interventions. Mr. Taylor responded that during the pandemic, there was too much data at times; the question is which data were needed for critical decisions, e.g., real-time hospital utilization. Dr. Ammon agreed that clear objectives for data use are critical and argued that it is important to define what “real-time” means, as there is a certain lag for all data entered by health systems, providing the example of the elapsed time that occurs between the incident of infection and registration by a laboratory diagnosis.

Prof. Sachs closed the session by thanking all speakers for their leadership and clarity, and emphasized the main takeaways of the webinar, including the development of career paths and compensation for health workers. He stated that these issues will be central at the World Health Assembly, the G20 discussions on SDG financing, and Preparedness funding.