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Review: WHO calls for building ‘Resilient Health Systems’ for Universal Health Coverage & Security

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The WHO recently released a position paper titled ‘Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond’. The paper argues that countries must build on investments made and lessons learned during the COVID-19 pandemic to create a ‘new normal’ of renewed health policies and systems.

In this article, we look at the major recommendations put forward in World Health Organisation’s (WHO) position paper titled ‘Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond’.

The paper argues that countries must build on investments made and lessons learned during the COVID-19 pandemic to create a ‘new normal’ of renewed health policies and systems.

The paper emphasises universal health coverage (UHC) and health security as being complementary goals. It provides rationale and recommendations for doing the same by the following means: 

  • Recovery and transformation of national health systems through investment in the essential public health functions (EPHF, also known as “common goods for health”), with a focus on primary health care (PHC) and the incorporation of health security.
  • All-hazards emergency risk management, to ensure and accelerate the sustainable implementation of the International Health Regulations (IHR), 2005.
  • A whole-of-government approach to ensure community engagement and whole-of-society involvement. 

High non-COVID-19 morbidities due to new barriers, disruptions in essential healthcare

At the onset, the paper acknowledges setbacks in health gains and efforts to achieve universal health coverage (UHC) caused due to the Coronavirus pandemic. Even countries scoring well on traditional health security and universal health coverage (UHC) measures have struggled with responding to and managing the risks of this pandemic. The pandemic hit vulnerable populations particularly hard, and COVID-19 has exacerbated pre-existing inequalities even further.

New barriers to the demand for health care, such as restricted movements, reduced ability to pay and fear of infection, have posed additional and unprecedented challenges in public healthcare. Preliminary estimates suggest the total number of global deaths attributable to the COVID-19 pandemic in 2020 due to, for example, interrupted vaccination programmes, maternal and child health services and non-communicable disease and mental health programmes are at least 3 million.

A WHO survey reported that 36 out of 70 countries had experienced disruptions in over 50% of their essential health services. As more evidence becomes available, it is probable that excess morbidity and mortality from non-COVID-19 conditions will be found to compare with COVID-19 figures, the paper suggests.

Moreover, the second round of a WHO’s Pulse survey revealed that over one year into the COVID-19 pandemic, substantial disruptions persist, with about 90% of countries still reporting one or more disruptions to essential health services, marking no substantial global change since the first survey conducted in the summer of 2020. Within countries, however, the magnitude and extent of disruptions have generally decreased. In 2020, countries reported that, on average, about half of essential health services were disrupted. In the first 3 months of 2021, however, they reported progress, with just over one-third of services now being disrupted.

To take a case in point, International Food Policy Research Institute (IFPRI) conducted surveys to compare the use of public health and nutrition services before, during and after COVID-19 lockdowns in the state of Uttar Pradesh in India. The survey states that the pandemic caused disruptions to both the supply of and demand for health services that persisted past the lifting of lockdown measures.

During the lockdown, almost all services ceased. Only 4% of frontline health workers provided services at community health and nutrition events, 29% conducted home visits, 1% continued antenatal care, and 5% monitored child growth, corresponding to reductions in the provision of these services ranging from 50 to 99 percentage points. On the demand side, the study found a substantial reduction between 40 and 80 percentage points in household use of these services during the lockdown—without much improvement after it ended. 

By July 2020 (post-lockdown), most services had resumed but their availability was still lower than during the pre-pandemic period. Despite extra efforts from frontline workers during and after lockdowns, beneficiaries remained fearful of COVID-19 infection and used those services at significantly lower rates than before the pandemic.

The resilience of essential healthcare as important as emergency response

In the backdrop of the above observations, a primary strong recommendation of the WHO’s position paper is that maintaining essential health services must be considered just as high a priority as ensuring the emergency response. Initial pandemic preparedness and response strategies gave inadequate attention to the potential consequences of disruption of essential services due to the repurposing of health system capacity and the introduction of new public health and social measures. 

COVID-19 has also put a spotlight on chronic foundational gaps in health systems that have made service delivery vulnerable to disruption and a potential risk factor in transmission. It highlighted the weak PHC orientation of many systems including fragmented care, hospital-centric systems, low levels of health literacy, etc.

Thus, as the paper argues, it has become increasingly clear that traditional efforts to strengthen health systems have not ensured adequate investment in common goods for health. The countries that were better able to contain the virus with less collateral economic damage seem to be the ones that could draw on an effective public sector and on a form of governance that emphasized engagement of populations, communities, and civil society.

PCH for UHC Approach

To address the above concerns, the paper urges to adopt the primary health care (PHC) approach in tandem with essential public health functions (EPHFs). A PHC is the first point of contact between individual, community health and national systems; it constitutes a critical interface with health security and a precursor to health emergencies. A PHC-for-UHC approach would support health security by preventing outbreaks through immunization and maintenance of essential health and social care services while hospitals are overwhelmed.

There is a need for more explicit recognition of the role of PHC in all-hazards emergency risk management and the building of resilient health systems and communities. Emerging evidence indicates that PHC and associated hospital reform can contribute significantly to health security, improving the responsiveness of health systems through the provision of integrated public health and primary care capacity in the front line.

The paper argues that countries now have a momentous window of opportunity to do things differently and fulfil their commitment to strengthening health systems, building
on the PHC approach and investing in EPHFs.

The COVID-19 pandemic has brought a huge political impetus and grassroots awareness to make health and resilience a top political priority. The global health community’s current challenge is thus to fully leverage this attention to ensure that countries reform, transform and upgrade their health systems and communities.

While chronic underfunding is common in many countries, there are countries where resources are not the only barrier. The cost of ensuring UHC and health security in 67 countries, as calculated by WHO, is extremely low compared with the cost of a crisis such as the current pandemic or future threats, including climate change.

Even the global cost of ensuring UHC and health security, as calculated by WHO, is extremely low compared with the cost of the pandemic and future threats such as climate change. Further, estimates concur that improving emergency preparedness is very affordable, with estimates ranging from less than USD 1 per person per year in low- and middle-income countries to between USD 1 and USD 5 per person per year – considerably less than any health emergency response.

Importance of PHCs in Kerala’s COVID-19 response

To take a case in point in India, Kerala’s success in managing the pandemic has been attributed to three things: an empowered local government system; a well-functioning primary healthcare network; and lessons from the Nipah virus.

Kerala has strengthened its efforts in primary healthcare over the last 15 years. With the Aardram mission, the State focused on preventive, promotive, and rehabilitative healthcare interventions. Over time, the interventions enshrined in the mission such as People-friendly Outpatient Services, re-engineering PHCs into FHCs (family healthcare centres), and standardization of services from primary care settings to tertiary settings played a key role in transforming primary healthcare centres.

In 1996, the Government of Kerala launched the People’s Plan Campaign (PPC), which devolved 35% of the state’s development budget from a centralised bureaucracy to local governments. By bringing primary and secondary healthcare came under the direct purview of local government, these funds helped districts improve the quality of care at primary health centres catering to their respective population’s needs. This system created strong accountability, better facilities over time, and a focus on service delivery at the primary health centre level.

The COVID-19 response plan in Kerala utilised the strong foundations of its PHCs. The PHC network across the state was empowered to:

  • Actively monitor the COVID-19 patients in home isolation.
  • Conduct timely blood sample investigations on high-risk patients for inflammation, clots, signs of damage to body tissues and capacity of the body to use oxygen on the seventh day from the onset of symptoms.

The state’s efforts and competent COVID-19 response have been noted by various national and international organisations, including WHO. Though Kerala has been reporting a high number of cases over the last few months, the case fatality rate is low. 

Address pre-existing inequalities, exacerbated by COVID-19

The pandemic has hit populations in situations of fragility, conflict, violence (FCV) and other vulnerabilities particularly hard. The paper estimates that the pandemic posed a particular threat for the estimated 25% of the global population living in FCV settings, where 60% of preventable maternal deaths, 53% of deaths in children under 5 years and 45% of neonatal deaths occur. While the health systems in these FCV settings were already struggling to meet basic health needs, now, the significant impact of containment measures and barriers has exacerbated the complex social, political and security contexts. It has made disease control, continuity of health service delivery, food security and inclusive governance an even greater challenge.

The paper highlights that all countries, regardless of income group (including those undergoing a chronic economic downturn), have populations with particular socioeconomic and health vulnerabilities, which must be addressed through health and social protection measures.

These measures should include removing financial barriers to high-quality health care (to ensure that people have access to coronavirus testing and treatment and other essential health services), enhancing income and job security, reaching out to those employed in the informal economy, and improving the delivery of social protection, employment, and other interventions.

Leverage tech and maintain consistent reliable healthcare communication

The paper emphasises that COVID-19 has shown how health systems must catch up with society by using innovative methods and new technologies. For instance, the demand for telemedicine existed before the pandemic, but its adoption has been accelerated to reduce health worker and patient contact and interruptions in treatment.

The pandemic has also driven research and innovation opportunities across the life sciences, digital health, medical technologies, vaccine development, therapeutics, and diagnostics and in self-care modalities. The paper suggests that countries will need to maintain an enabling environment to advance these developments, while also managing the evolving risks and challenges associated with them (e.g., privacy and inequity concerns). 

For example, India’s Aarogya Setu contact-tracing app developed by a unique public-private partnership was plagued by concerns of data safety and user privacy. Experts in the field pointed out that the application poses serious privacy challenges because India currently lacks a comprehensive data protection law, surveillance, and interception laws.

Social media have been a major source of both credible information and misinformation; governments with community participation must learn to navigate them faster and more effectively. In this context, the paper recommends building and maintaining public trust through community engagement and participation is key.

In the backdrop of this, the report emphasised that clear, consistent, and reliable risk communication and proactive dialogue with communities helped to reduce public dissatisfaction and infodemic and increase their willingness to participate. Longstanding community health worker programmes and initiatives to build community resilience served as reliable platforms to contextualize measures to meet local needs.

Vaccine hesitancy serves as an example of a major mis-information hurdle faced by certain developed as well as developing countries. In India, fear of side-effects from newly developed vaccines, rumours about infertility and death post-vaccination, combined with the initial inconvenience (and also cost) of registration slots, and the absence of incentives for rural and urban poor etc. continue to fuel vaccine hesitancy. 

To tackle the problem of health misinformation, Factly’s health microsite is designed to provide comprehensive information on the myths & rumours in various areas of health. 

It also hosts well-researched & verified information to tackle health misinformation, particularly in the wake of the COVID-19 pandemic in the form of a Podcast, health misinformation report among other things. 

Featured Image: Universal Health Coverage

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