Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond - WHO POSITION PAPER
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WHO POSITION PAPER
Building health systems
resilience for universal
health coverage and
health security
during the COVID-19
pandemic and
beyond
WHO POSITION PAPER Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond
WHO/UHL/PHC-SP/2021.01 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: WHO position paper. Geneva: World Health Organization; 2021 (WHO/UHL/PHC- SP/2021.01). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
Contents iii
Contents
v Acknowledgements
vi Acronyms
viii Executive summary
1 I. Introduction
7 II. Lessons from the COVID-19 pandemic
11 III. Policy recommendations and actions
to build resilient communities and
PHC-based health systems
22 IV. WHO’s commitment to supporting
Member States and communities
in relaunching progress towards
universal health coverage and health
security
26 Glossary
29 References
© WHO / Blink Media - Martyn Aim Cover Photo: © WHO / Oleksii Ushakov
Acknowledgements v
Acknowledgements
This position paper Reviewers and contributors from
was developed through WHO headquarters and regional
collaboration between offices: Pascale Abie, Hala Abou Taleb,
headquarters and all Benedetta Allegranzi, Sophie Amet,
regional offices of WHO, Roberta Andraghetti, Ali Ardalan,
under the leadership of Zsuzsanna Jakab Ian Askew, Anshu Banerjee, Anil
(Deputy Director-General, WHO) and Bhola, James Campbell, Alessandro
Mike Ryan (Executive Director, WHO Cassini, Jorge Castilla, Ogochukwu
Health Emergencies Programme) with Chukwujekwu, Giorgio Cometto, Peter
further guidance from Jaouad Mahjour Cowley, Sofia Dambri, Neelam Dhingra-
(Assistant Director-General, Emergency Kumar, Khassoum Diallo, Abdul Ghaffar,
Preparedness, WHO). Ann-Lise Guisset, Lynne Harrop, Qudsia
Huda, Humphrey Karamagi, Masaya
The responsible technical and Kato, Rania Kawar, Edward Kelley, Devora
coordination team comprised Sohel Kestel, Hala Khudari, Joseph Kutzin, Yue
Saikat, Marc Ho, Dheepa Rajan and Liu, Mwelecele Malecela, Paul Marsden,
Andre Griekspoor and was led by Suraya Robert Marten, Nikon Meru, Hernan
Dalil, Stella Chungong and Gerard Montenegro Von Mühlenbrock, Saqif
Schmets. Mustafa, Matthew Neilson, Hyppolite
Ntembwa, Denis Porignon, Adrienne
At the regional level, leadership and
Rashford, Tomas Roubal, Cris Scotter,
coordinated contributions were provided
Redda Seifeldin, Kabir Sheikh, Zubin
by directors and leads responsible for
Shroff, Ian Smith, Rajesh Sreedharan,
programme management, universal
Shamsuzzoha Syed, Regina Titi-Ofei,
health coverage and life course, and
Anthony Twyman, Jun Xing, Kenza
health emergencies: Natasha Azzopardi-
Zerrou, Yu Zhang, Zandile Zibwowa.
Muscat, Jarbas Barbosa da Silva (Junior),
Joseph Cabore, James Fitzgerald, Rana
Hajjeh, Melitta Jakab, Awad Mataria,
Pem Namgyal, Dorit Nitzan, Martin Taylor,
Prosper Tumusiime, Jos Vandelaer, Liu
Yunguo, Felicitas Zawaira.
vi
Acronyms
© WHO / Tom Pietrasik
Cover Photo: © WHO / Oleksii Ushakov
Acronyms vii AAR after-action review ACT Access to COVID-19 Tools CGH common goods for health COVID-19 coronavirus disease CPRP COVID-19 country preparedness and response plans EPHF essential public health functions FCV fragility, conflict and violence GDP gross domestic product GPW13 WHO’s Thirteenth General Programme of Work IAR intra-action review IHR (2005) International Health Regulations (2005) NAPHS National Action Plan for Health Security NHSP national health sector policies PHC primary health care PPE personal protective equipment SDG Sustainable Development Goal SPRP Strategic Preparedness and Response Plan UHC universal health coverage UHC 2030 International Health Partnership for UHC 2030 UN the United Nations WHA World Health Assembly WHO World Health Organization
viii
Executive summary
© WHO / Lindsay MackenzieExecutive summary ix
Novel coronavirus disease (COVID-19) • recovery and transformation of
has had a wide-ranging impact on all national health systems through
areas of society, leading to setbacks investment in the essential public
in health gains and efforts to achieve health functions (EPHF)i and the
universal health coverage (UHC). The foundations of the health system, with
diversion of health system resources a focus on the primary health care
to address COVID-19 care led to a (PHC) and the incorporation of health
protracted disruption of essential health security;
services. New barriers to the demand
for health care, such as restricted • all-hazards emergency risk
movements, reduced ability to pay and management, to ensure and
fear of infection, have posed additional accelerate sustainable implementation
and unprecedented challenges, to say of the International Health Regulations
nothing of the stark reality, in many (2005) (IHR 2005);
settings, of insufficient infection prevention
• whole-of-government approach to
supplies and testing capacity.
ensure community engagement and
The world has not learned from previous whole-of-society involvement.
epidemics, and overreliance on reacting
This paper provides leaders and policy-
to events as they occur, rather than on
makers at national and local levels with
prevention and preparedness, has meant
the following recommendations for the
that countries were caught unprepared
medium and long term, positioning
for a pandemic of this speed and scale.
health within the wider discussions
Unfortunately, the pandemic has also hit
on socioeconomic recovery and
vulnerable populations particularly hard,
transformation:
and COVID-19 has exacerbated pre-
existing inequalities even further. 1. Leverage the current response
to strengthen both pandemic
UHC and health security are
preparedness and health systems:
complementary goals; this position
this includes using results from intra-
paper provides a rationale and
action and after-action reviews (IAR/
recommendations for building resilience
AAR) and multisectoral reviews to
and seeking integration between
inform sustained investment in health
promoting UHC and ensuring health
system strengthening; identifying
security by the following means:
and mapping existing resources
and weaknesses in capacities to
determine priority needs; updating
country preparedness and response
plans and socioeconomic recovery
i Also recently referred to, from an economic perspective, as “common goods for health”, see: Common
goods for health. In: www.who.int [website]. Geneva: World Health Organization; 2020 (https://www.
who.int/health-topics/common-goods-for-health#tab=tab_3, accessed 7 November 2020).Building health systems resilience for universal health coverage and health security
x during the COVID-19 pandemic and beyond
plans; embedding policies and prioritize essential services and PHC
planning for emergency management appropriately; and investing in safe,
within wider efforts to strengthen secure, accessible and sustainable
health systems; and ensuring wider PHC facilities that provide high-quality
stakeholder participation in intra-action services.
and after-action reviews underpinning
One Health approach. 4. Invest in institutionalized
mechanisms for whole-of-
2. Invest in essential public health society engagement: this includes
functions including those needed reviewing existing mechanisms for
for all-hazards emergency the whole-of-society engagements;
risk management: this includes developing institutional and
increasing investment to address legislative instruments to mobilize
critical gaps in EPHF; conducting whole-of-government and whole-
EPHF and IHR capacity assessments of-society resources; advocating,
as part of multisectoral reviews of mainstreaming and monitoring
health system and public health whole-of-society approaches in
capacity; strengthening health emergency preparedness, response,
and public health professionals’ essential health services and recovery
competencies in the EPHF and their efforts; developing health workforce
role in emergency management; capacity for engagement with and
and conducting policy dialogue to empowerment of the population;
promote the embedding of EPHF in adapting policies and planning
administrative structures. with monitoring and accountability,
underpinned by national legislation, to
3. Build strong Primary Health Care mandate the role of and support for
foundation: this includes ensuring local governments; and supporting
strong political commitment and global mechanisms to ensure
leadership to place PHC at the heart equitable access to products in limited
of efforts to attain UHC, health security supply.
and the United Nations Sustainable
Development Goals; implementing 5. Create and promote enabling
health services planning and environments for research,
organization modalities that promote innovation and learning: this
quality, people-centred primary care includes enabling regulatory
and the EPHF at their core; ensuring environments; maintaining and
adequate and sustainable quality, adapting innovative models
competency levels and distribution implemented during the pandemic
of a committed and multidisciplinary encompassing infodemics; providing
PHC workforce; ensuring that health regulatory support to facilitate inter-
system financing arrangements that country and intra-country informationExecutive summary xi
management, data-sharing and mobilizing additional public funds
coordination; and promoting research, and safeguarding and extending
innovation and learning in all-hazards coverage of health protection and
emergency risk management and health care provision mechanisms;
health system resilience. ensuring engagement, participation
and considerations of vulnerable
6. Increase domestic and global socioeconomic groups; supporting
investment in health system financial protection for vulnerable
foundations and all-hazards populations by pursuing social
emergency risk management: this protection policies to ensure income
includes identifying existing capacities security; monitoring inequities in
to determine the needs for long- health and access to health care
term health system strengthening to to inform policies, planning and
maintain essential health and social investment; and, in fragility, conflict
services including non-communicable and violence (FCV) settings, exploring
diseases and mental health and common concerns, challenges
health emergency preparedness; and opportunities to strengthen
creating legislation and policy the FCV triple nexus, defined as
frameworks to increase and sustain fostering strategic and operational
the fundamental requirements for connections between development
health systems and emergency and humanitarian programming and
preparedness; prioritizing investment linking with peace-building.
and financing for public health and
health security with consideration for WHO will collaborate with its
countries under protracted instability Member States, the United Nations
and fragile systems and governance, and other partners to support
based on identified capacity gaps and the implementation of the above
lessons learned; including investment recommendations, within the remit of
in health systems, resilience and the UN Framework for the Immediate
emergency preparedness of the Socio-economic Response to
agenda for regional cooperation COVID-19. At national level, the role
bodies’ investment planning; and of WHO country offices will be pivotal,
leveraging investment in non-health bolstering multisectoral, government-
sectors to support the strengthening led socioeconomic recovery and
of public health capacity. transformation processes. WHO will
also support ministries of health in
7. Address pre-existing inequities bringing together other line ministries,
and the disproportionate impact partners, civil societies, voluntary
of COVID-19 on marginalized sectors (both for profit and not for
and vulnerable populations: this profit), to promote the health agenda
includes guaranteeing access to and resource mobilization for PHC,
safe and high-quality health care by EPHF and emergency preparedness.Building health systems resilience for universal health coverage and health security
xii during the COVID-19 pandemic and beyond
This will complement and, where
appropriate, be integrated with
ongoing pandemic preparedness and
response planning.
WHO will harness the lessons
learned from COVID-19 and adopt
good practices. Moving forward,
it will review and improve existing
mechanisms for assessment,
monitoring and reporting of country
capacities and progress. WHO
will continue to support strategies
to address critical foundational
weaknesses of health systems in
countries with FCV settings.© WHO
1
I.
IntroductionBuilding health systems resilience for universal health coverage and health security
2 during the COVID-19 pandemic and beyond
As of the 23rd of June 2021, over 178 3 million (5). A WHO survey reported that
million people across the world have 36 out of 70 countries had experienced
been infected by the novel coronavirus disruptions in over 50% of their essential
SARS-CoV-2, causing 3,880,450 deaths health services. This is exacerbated
(1). The pandemic of novel coronavirus by new barriers to demand, such as
disease (COVID-19) has had far-reaching restricted movement to contain the
consequences for all parts of society, spread of COVID-19, reduced ability to
causing unprecedented disruption of pay and fear of becoming infected. As
health services as national authorities more evidence becomes available, it
struggle to cope. Stringent public health is probable that excess morbidity and
and social measures as a response to the mortality from non-COVID-19 conditions
current pandemic have grossly affected will be found to compare COVID-19
lives and livelihoods, plunging the world figures (6, 7).
economy into recession, to an estimated
amount of US$ 8.8 trillion (2020–2021), The pandemic has hit populations in
not to mention record unemployment (2). situations of fragility, conflict, violence
(FCV) and other vulnerabilities particularly
Progress made in many countries hard; those affected include refugees
towards United Nations Sustainable and internally displaced populations,
Development Goal (SDG) 3 has not only homeless people, elderly, people living in
stalled, but even threatens to regress, informal settlements or dependent on the
as health stewards are simultaneously informal sector for survival and high-risk
confronted with the pandemic response, communities exposed to other threats,
health system recovery and long-term including natural hazards and the impact
development challenges (3). of climate change. The adverse effects
are mostly caused by increased barriers
Even countries scoring well on traditional to accessing essential health services
health security and universal health and the lack of socioeconomic safety
coverage (UHC) measures have struggled nets. This is a particular threat for the
with responding to and managing estimated 25% of the global population
the risks of this pandemic (4). The living in FCV settings, where 60% of
burden of this struggle has been borne preventable maternal deaths, 53% of
disproportionately by the most vulnerable deaths in children under 5 years and
communities in all countries. 45% of neonatal deaths occur. Health
systems in these FCV settings were
Indeed, the price the entire global
already struggling to meet basic health
community has paid is high. Preliminary
needs even before the pandemic; now,
estimates suggest the total number
the significant impact of containment
of global deaths attributable to the
measures on lives and livelihoods as
COVID-19 pandemic in 2020 due to,
well as on barriers for utilization of health
for example, interrupted vaccination
services, has exacerbated the complex
programmes, maternal and child health
social, political and security contexts
services and noncommunicable disease
and made disease control, continuity of
and mental health programmes is at least
health service delivery, food security andI. Introduction 3
inclusive governance into an even greater The countries who were better able
challenge. to contain the virus with less collateral
economic damage seem to be the ones
It is thus becoming increasingly clear that could draw on an effective public
that traditional efforts to strengthen sector and on a form of governance that
health systems, previously considered emphasized engagement of populations,
the principal means of achieving UHC, communities and civil society (10, 11,
have not ensured adequate investment 12, 13, 14, 15). Based on observations
in common goods for health (CGH): from evolving evidence, countries that
those essential public health functions had made limited progress in UHC with
(EPHF) that only governments can health security seemed generally less
finance, because they are either public able to repurpose their capacities toward
goods or have large market failures. epidemic treatment, and their normal
These include the implementation of the services were more easily compromised
International Health Regulations (2005) (16).
(IHR 2005).i Countries have also relied
too heavily on reacting to events as they
occur, rather than taking proactive action Universal health coverage
to prevent, prepare for and reduce the and health security: two
risks of disasters and emergencies in
sides of the same coin
communities. The global prioritization of
the preventive action needed to ensure
These insights underscore the fact that
health security is described in the 2019
UHC and health security are two sides
annual report of the Global Preparedness
of the same coin (17, 18, 19) – two
Monitoring Board, which laments:
complementary health goals towards
“despite significant progress in assessing
which all countries should steer: people
deficiencies and developing plans,
able to use essential services when they
not a single National Action Plan for
need them, including during emergencies,
Health Security (NAPHS) has been fully
without suffering financial hardship.
financed” (8). A 2018 survey on pandemic
Despite the inherent synergies and
preparedness also found that, of the
overlaps in the actions needed to reach
54% of Member States that responded,
those goals, the approach to date at
88% had national pandemic influenza
both global and national levels has been
preparedness plans, but almost half of
fragmented (20).
these (48%) had been developed before
the 2009 H1N1 pandemic and had not A primary health care (PHC) approach
been updated since (9). in tandem with EPHFs are not only
critical to achieve UHC but also to health
i The legally binding International Health Regulations (2005) support countries in managing emergencies
through stronger national capacities for preparedness and response in ways that are commensurate
with, while being restricted to, public health risks, avoiding unnecessary interference with international
traffic and trade.Building health systems resilience for universal health coverage and health security
4 during the COVID-19 pandemic and beyond
security. PHC is the first point of contact While chronic under funding is common in
between individual, communities health many countries, there are countries where
and national systems so constitutes resources are not the only barrier. The
critical interface with health security cost of ensuring UHC and health security
and a precursor to health emergencies. in 67 countries, as calculated by WHO, is
Besides offering a strong orientation for extremely low compared with the cost of
efforts to strengthen health systems, a crisis such as the current pandemic or
the PHC-for-UHC approach supports future threats, including climate change
health security by preventing outbreaks (23, 24, 25, 26, 27). Further estimates
through immunization and maintenance concur that improving emergency
of essential health and social care preparedness is very affordable, with
services while hospitals are overwhelmed estimates ranging from less than US$ 1
(21, 22). The PHC approach also aims per person per year in low- and middle-
to reduce all health risks and address income countries (28) to between US$ 1
determinants of health; it thus lays the and US$ 5 per person per year (29)
foundation for all-hazards emergency – considerably less than any health
risk management, whereas emergency emergency response. It means that
response relies on existing treatment countries can build resilience by investing
capacities to scale up epidemic treatment in governance, key preparedness and
and existing community engagement for response capacities and PHC as the
risk communication. foundation for addressing the population’s
essential health needs, while protecting
Countries now have a momentous the population from emergencies. In the
window of opportunity to do things end, the synergies gained by addressing
differently and fulfil their commitment to UHC and health security simultaneously
strengthening health systems, building leave us collectively better off, from both a
on the PHC approach and investing in financial and a health point of view.
EPHFs. The COVID-19 pandemic has
brought a huge political impetus and
grassroots awareness to make health and © WHO
resilience a top political priority. The global
health community’s current challenge
is thus to fully leverage this attention to
ensure that, in recovering and building
better during and beyond COVID-19,
countries reform, transform and upgrade
their health systems and communities
with both health security and UHC in
mind.I. Introduction 5
Objective of the paper consultative process applied led to a
compilation of key lessons from the
COVID-19 pandemic and past events,
This WHO position paper provides a
which informed the development of policy
rationale and recommendations
and allied recommendations and the
for building resilience by seeking
role of WHO with stakeholders in relation
integration between promoting UHC and
to building resilient health systems.
ensuring health security through:
Following the development of this Position
• recovery and transformation of Paper, a Position Brief was developed
national health systems through to provide a more concise version,
investing in strengthening EPHF, and mainly targeting heads of governments,
the foundations of the health system, ministries of finance and other leaders
with a focus on the PHC and the within and outside the health sector. The
incorporation of health security; key messages to various stakeholders,
summarized in the Position Brief also
• all-hazards emergency risk reflect the expertise, experiences and
management, to ensure and consensus between the WHO leadership
accelerate sustainable implementation and technical experts working on
of IHR (2005); promoting an integrated approach to
making health systems resilient for the
• inclusive governance to ensure achievement UHC and health security in
community engagement and whole- tandem.
of-society involvement.
This paper is also complementary to, and
The overarching axiom will be to move synergistic with, recent joint publications
away from “panic and neglect” towards on recovery and transformation. These
“building back better”. The timescale include the revised COVID-19 Strategic
for the recommendations is the medium Preparedness and Response Plan
and long term. The paper will build on (SPRP), and the UN Framework for the
and complement WHO’s strategic and Immediate Socio-economic Response to
operational support for the ongoing COVID-19, which lays out the principal
preparedness and response efforts and elements of a positive recovery process
early recovery needs (30). (31). This paper sets out WHO’s vision for
a transformed health sector which has
Approach applied to taken the lessons of COVID-19 seriously,
within the framework set out by the
develop the Position
United Nations for a socially just society
Paper and its Brief and an equity-conscious economy. Also,
the WHO Manifesto for a healthy recovery
The development of this WHO position from COVID-19 gives us a sharp reminder
paper drew from existing work, guidance that environmental determinants are
and expertise within WHO through the root cause of the current pandemic
extensive consultations and reviews at and need to be addressed as well (32).
headquarters and regional levels. The It is aligned with the Primary HealthBuilding health systems resilience for universal health coverage and health security
6 during the COVID-19 pandemic and beyond
Care Operational Framework (33) and
contributes to all objectives of the three
bold targets of the WHO 13th General
Programme of Work (GPW13) (34).
This paper also complements ongoing
initiatives to review national pandemic
preparedness and UHC, to inform
planning and interventions for building
back better. Such initiatives include
the Assessment of Gaps in Pandemic
Preparedness presented to G20 Leaders,
and Universal Health and Preparedness
Review Mechanism (forthcoming).
Target audience
This paper targets leaders and policy-
makers at national and local levels. It
includes key stakeholders, including
national public health institutes, civil
society, private (both for profit and
not for profit) sector, parliamentarians,
emergency managers, humanitarian and
development partners and the United
Nations community, in addition to those
working in ministries and other sectors
that support health.© WHO
7
II.
Lessons from the
COVID-19 pandemicBuilding health systems resilience for universal health coverage and health security
8 during the COVID-19 pandemic and beyond
Countries must build on investments due to repurposing of health system
made and lessons learned during the capacity and the introduction of new
COVID-19 pandemic in order to create public health and social measures. Some
a “new normal” of renewed health of the enormous strain that COVID-19
policies and systems. Some of the placed on secondary and tertiary services
lessons learned during the COVID-19 could have been avoided (36). Some
response are listed below to inform PHC-oriented health systems have
recommendations and policy orientations demonstrated resilience, quickly adapting
for recovery and transformation. and maintaining essential services by
rebalancing clinical loads across levels
All countries need to improve their of care, including the roles of different
organization and functioning of levels health services delivery in detecting
health systems and beyond for cases early, managing simpler cases
pandemic preparedness: before the close to the community and employing
pandemic, most national health systems triage to protect hospital capacity. This
had been able to function adequately also reduces excess non-COVID-19
with only basic preparedness measures morbidity and mortality. Primary care
in place to address more frequent but services are often also the entry point to
small-scale emergencies. This had the health system; surveillance linked with
led to complacency, resulting in gaps diagnostics is crucial at this level.
in EPHF and capacities necessary
for IHR (2005) implementation (35). Countries need to invest in
Moreover, countries had not adequately addressing foundational health
anticipated or planned for national system gaps and essential public
emergencies exceeding those capacities, health functions for emergency
nor for the resulting disruption to essential management: COVID-19 has put a
health services. This led to inadequate spotlight on chronic foundational gaps in
governance, coordination and incident health systems that have made service
management as well as gaps in clinical delivery vulnerable to disruption and a
management pathways, standards of potential risk factor in transmission (e.g.
care, infection prevention and control, poor adherence to infection prevention
and the ability to flexibly deploy workforce and control and water, sanitation and
to areas of greatest need. This was true hygiene standards and chronically
even of countries that were considered understaffed health facilities as well
to have mature health systems and as functions such as contact tracing,
advanced IHR core capacities. quarantine, isolation and resilient
supply chains). It highlighted weak PHC
Maintaining essential health services orientation of many systems including
must be considered just as high a fragmented care, hospital-centric
priority as ensuring the emergency systems, low levels of health literacy, and
response. Initial pandemic preparedness the lack of effective health emergency
and response strategies limited to give management systems, including
adequate attention to the potential education, basic training and professional
significant disruption of essential services development in emergency preparednessII. Lessons from the COVID-19 pandemic 9
and response for health and social Building and maintaining public trust
care workers and managers, including through community engagement
the adoption of flexible roles. These and participation is key: trust in
health system elements are essential for governments, public services and health
achieving UHC and health security. systems represents social capital built
up over time through active two-way
Governance and leadership are communication and engagement with
critical for effective emergency risk populations, communities and civil
management with multisectoral society. Clear, consistent and reliable risk
coordination: governments that communication and proactive dialogue
acknowledged the health threat early, with communities helped to reduce
had populations that trusted their public dissatisfaction and infodemics and
leadership, made decisions based on increase their willingness to participate.
available evidence and coordinated Longstanding community health worker
preparedness and response across programmes and initiatives to build
sectors seemed to do better in stemming community resilience served as reliable
community transmission. Successful platforms to contextualize measures to
measures included pooling resources meet local needs. Local risk management
across line ministries, private sectors approaches and community-based
and employing effective coordination surveillance systems for seasonal threats
structures. Decentralized multisectoral also helped in developing effective
risk and emergency management, interventions.
embedded in local structures and
using the PHC approach, allowed Global emergencies compromise
much needed flexibility at local levels the scope for external support and
to address the constantly evolving resources as each country struggles
situation effectively. Fragmentation in with its own national response: the
the organization and governance of key pandemic laid bare the impact of a large-
health system functions, as well as in scale emergency which simultaneously
financing and coverage arrangements, exceeds individual national capacities
undermines leads to leadership and rapidly overwhelms all countries
hesitancy and the ability to engage in a at once. Unlike localized and regional
population-based response. In countries public health emergencies, this situation
where health coverage arrangements leads to reduced external support for the
were fragmented and dependent countries most in need. The problem is
on specific financial contributions, exacerbated by severe global shortages
there was a lack of resilience to the and competition for critical resources,
economic shock of COVID-19, leading such as personal protective equipment
to a loss of coverage. Key cross-cutting (PPE), reagents and medicines.
functions (e.g. surveillance) and systems
(e.g. information) are needed across
programmes and schemes.Building health systems resilience for universal health coverage and health security
10 during the COVID-19 pandemic and beyond
Technology and new ways of employment and social welfare benefits,
organizing health services are playing leaving no one behind. Moreover, the
a stronger role in providing alternative macroeconomic and fiscal implications of
platforms for health service delivery the COVID-19 pandemic may persist for
and epidemic response: COVID-19 years, threatening to compromise past
has shown how health systems must progress towards UHC. In response to
catch up with society in using innovative the pandemic, countries have increased
methods and new technologies. The health and social spending while public
demand for telemedicine existed before revenues have fallen, leading to growing
the pandemic, but its adoption has been fiscal deficits and increasing debt
accelerated to reduce health worker burdens. This may constrain the amount
and patient contact and interruptions that governments can spend on health.
in treatment. Many countries’ manual Protection of access to health care for
contact tracing attempts have been the poor and protection against financial
complemented by app-based solutions hardship will remain critical priorities.
(37). Social media have been a major
source of both credible information Emergency risk management is a
and misinformation; governments with common good for health and needs
community participation must learn to to be publicly funded and organized:
navigate them faster and more effectively. public governance of health systems, with
As such, there is a need to balance predominant reliance on public funding
between the opportunities and challenges sources, is essential to enable progress
that the technology revolution era brings. towards UHC and health security. Where
these are inadequate, there is a high risk
COVID-19 has magnified inequity, of exacerbating pre-existing inequalities
health and socioeconomic disparities, in access, particularly when independent
disproportionately impacting or private providers and insurers can set
marginalized and vulnerable their own prices or exclude the persons in
people: COVID-19 has uncovered greatest need (40). Similarly, at the global
and exacerbated pre-existing health level, the restrictions in global transport
and socioeconomic inequalities within have led to supply chain constraints and,
societies arising from the impact of in some cases, inadequately managed
stringent measures that have disrupted market mechanisms have resulted in
both the formal and the informal economy limited supplies being allocated to the
(38). According to the International highest bidder rather than to those with
Labour Organization, 1.6 billion workers the greatest need. This has also been a
in the informal economy – nearly half the major problem in the roll-out of COVID-19
global workforce – are at risk of losing vaccines worldwide.
their jobs (39). The global community
needs to accelerate progress urgently
in building social protection packages
that embed UHC in social protection
to ensure financial protection and
access to essential health services,© WHO
11
III.
Policy recommendations
and actions to build
resilient communities
and PHC-based health
systemsBuilding health systems resilience for universal health coverage and health security
12 during the COVID-19 pandemic and beyond
The world has faced health threats term post-COVID-19 recovery and
and emergencies before, including the transformation for resilience.
outbreaks of severe acute respiratory
syndrome, Middle East respiratory Investment in health system recovery
syndrome coronavirus, pandemic and transformation will not only be
influenza A (H1N1) and Ebola virus cost-effective, reducing the health
disease. However, there has been lack and socioeconomic impact of future
of sustained programmatic approach pandemics, which are likely to happen
to recovery to build resilience in health more frequently than in the past; they
systems and communities, maintain will also reduce the risks and impact
EPHF and strengthen emergency of smaller-scale but more frequent
preparedness and response capacities. epidemics and shocks, and also
Funding and political impetus usually contribute in general to better health for
decline soon after the response phase, all and bring macroeconomic and social
with poor integration with longer-term benefits.
recovery and transformation.
1. Leverage the current
WHO calls on countries to take action
towards recovery and transformation response to strengthen
of their national and subnational health both pandemic
systems. This can be achieved by
preparedness and
investing in and strengthening EPHF
and an all-hazards risk management health systems
approach, including implementation
of IHR (2005) and PHC-based health Given the protracted nature of COVID-19,
systems with whole-of-society current investment in preparedness and
involvement to achieve UHC and health response needs to be institutionalized
security. To ensure functionality of health and converted into early recovery and
systems during emergency response and transformation activities for the longer-
recovery, fundamental requirements must term. This will ensure that response
be in place. interventions during the pandemic
contribute to medium- and longer-term
WHO proposes the following policy national and subnational capacity-building
recommendations and actions for emergency risk management and
for countries to inform planning, continuity of essential health services.
investment and interventions by all This early recovery should be informed
relevant stakeholders, to build resilient by the existing risks, gaps, priorities and
communities and PHC-based health reforms, as already identified before
systems. These will be relevant to the pandemic, for example through
ongoing preparedness and response country risk profiles, IHR monitoring and
to control the epidemic and mitigate evaluation framework assessments,
the effect on high-quality essential national action plans for health security
services, so that this investment will lay (NAPHS) and national health sector
the foundation for medium- to longer- policies (NHSP), and aligned with anIII. Policy recommendations and actions to build resilient communities and PHC-based health systems 13
all-hazards emergency risk management • Embed policies and planning for
approach. emergency management in wider
efforts to strengthen health systems
This early recovery approach should be (and vice versa), by applying an
integrated into ongoing preparedness integrated approach to UHC and
and response plans and guidance, health security policy-making and
e.g. through revised COVID-19 country subsequent planning.
preparedness and response plans
(CPRP) which, in turn, should provide the • Ensure participation of health
foundation for a “health first” approach in systems, stakeholders in emergency
socioeconomic response plans, as per preparedness and response, other
the UN Framework for the Immediate sectors and community partners in
Socio-economic Response to COVID-19. IARs and AARs, so that response
experiences influence sustainable
Actionable recommendations capacities for a more resilient system.
• Use the results of IARs and AARs
(41) and multisectoral reviews of the 2. Invest in essential
health and socioeconomic impact public health functions,
of COVID-19 to inform sustained
investment in health system
including those
strengthening, integrating all-hazards needed for all-hazards
risk management and emergency emergency risk
preparedness.
management
• Identify existing resources and
weaknesses in capacity to determine EPHF include surveillance, governance/
priority areas of need. This would financing, prevention, health promotion
strengthen capacity to provide high- and risk reduction, health protection/
quality, resilient services for other legislation, public health research
conditions, including life-course- and human resources, procurement
specific diseases, communicable and access to essential medications,
diseases, noncommunicable diseases laboratory capacities and supply and
and mental health conditions. This logistics chains, recognizing contextual
also includes infection prevention differences in their application (42).
and control to ensure the safety of
the health workforce, patients and To invest in EPHFs across different
communities. sectoral structures and all levels of the
health system, countries may consider the
• Where needed, update CPRP and following actionable recommendations.
socioeconomic recovery plans to Actionable recommendations
include early recovery approaches
and ensure related additional • Increase domestic and global
investment as required. investment to address critical gaps in
EPHFs, particularly those necessaryBuilding health systems resilience for universal health coverage and health security
14 during the COVID-19 pandemic and beyond
for the implementation of IHR (2005) 3. Build strong Primary
using an all-hazards risk management
approach.
Health Care Foundation
for resilient health
• Conduct EPHF and IHR capacity
assessments as part of multisectoral
systems for UHC, the
reviews of health system and public health-related SDGs
health capacity in the context of and Health Security
COVID-19.
While PHC is recognized as a cornerstone
• Strengthen health and public health
for achieving UHC, in line with the Astana
professional competencies in EPHF
Declaration (43), there is a need for more
and their role in risk and emergency
explicit recognition of the role of PHC in
management (integrated where
all-hazards emergency risk management
appropriate with broader health
and the building of resilient health
workforce planning). This includes
systems and communities. PHC is rooted
working with and promoting the
in a commitment to social justice, equity,
stewardship of national public health
solidarity and participation. It is based
institutes that are often custodians of
on the recognition that the enjoyment
many EPHFs.
of the highest attainable standard of
• Conduct policy dialogues on EPHF, health is one of the fundamental rights of
to be embedded in administrative every human being without distinction.
structures from national to local Emerging evidence indicates that
levels, with a robust foundation for PHC and associated hospital reform
PHC, especially those with critical can contribute significantly to health
interdependencies with health, in security, improving the responsiveness
order to promote awareness. of health systems through the provision
of integrated public health and primary
• Implement the ‘safe health facilities’ care capacity in the front line (44, 45,
programme at all three levels of the 46, 47) combined with high-quality
health system. hospital services. PHC should be the
main community interface with the health
system, where all-hazards emergency
preparedness efforts can begin to
build community resilience (48). Many
countries’ responses have been focused
© WHO / Lorenzo Pezzoli
on expanding intensive-care hospital
capacity for severe COVID-19 patients.
Although this is hugely significant, a large
proportion of the health services needed
by those affected have been provided
through primary care and community
services, which is essential to ensureIII. Policy recommendations and actions to build resilient communities and PHC-based health systems 15
the safety of staff and patients and the and support them in preparing
continuity of essential and routine health and responding more effectively
care. to emergencies while maintaining
essential health services.
Actionable recommendations
• Ensure that health system financing
• Sustain strong political commitment arrangements appropriately prioritize
to and leadership of health system essential services in alignment with
strengthening, with PHC at the the 2019 UN High Level Declaration
heart of efforts to attain UHC, health on UHC which recommends that at
security and the SDGs (43). This least an additional 1% of GDP spent
includes defining and implementing into PHC, so that the inputs available
benefits packages for health are sufficient to enable high-quality
services, supported by appropriate care and services and that entitlement
financing and workforce policies; conditions support equity in access.
developing policy frameworks and Promote purchasing and payment
regulations; building multisectoral systems that foster a reorientation
governance and partnerships; and in models of care towards greater
promoting community leadership and prevention and promotion and
accountability of providers and policy- towards care that is more coordinated
makers to the public. This should be across the continuum of care and
aligned with national health sector delivered closer to the places people
strategic planning live and work.
• Implement modalities of care that • Invest in safe, secure and accessible
promote quality, people-centred primary care facilities to provide high-
primary care and EPHF as the core quality services with reliable water,
of integrated health services provided sanitation, waste disposal/recycling,
by both public and private sector cold chains, medical supply chains,
providers and across both sectors. diagnostic facilities/laboratories,
Incorporate digital technologies for telecommunications connectivity and
health in ways that facilitate access power supply, and with transport
to care and service delivery, improve systems that can connect patients
efficiency, promote accountability, with other care providers.
support continuity of care and
two-way risk communication with
communities and households. 4. Invest in
institutionalized
• Ensure adequate and sustainable
numbers, competency levels
mechanisms for whole-
and distribution of a committed, of-society engagement
multidisciplinary PHC workforce
that includes facility-, outreach- and In many countries, including high-
community-based health workers income countries, health governanceBuilding health systems resilience for universal health coverage and health security
16 during the COVID-19 pandemic and beyond
has not included adequate and whole-of-government approach, the
regular mechanisms for engaging with pandemic has also underscored the need
populations, communities and civil society for global cooperation, empathy and
that can be utilised during emergencies. solidarity between countries and partners.
Acknowledging that health needs to
be integrated within broader societal Actionable recommendations
functions, the proposed transformation
• Review existing mechanisms for
should be based on a whole-of-
whole-of-society action, including
society approach with monitoring and
expanding multisectoral approaches
accountability. Mechanisms established
to health system strengthening and
for the One Health approach, involving
emergency management, community
collaboration with the animal health, food,
engagement, empowerment and
livestock and environment sectors, can
multi-stakeholder governance at all
form the basis for broader, multisectoral
levels of administration.
coordination platforms for all-hazards
emergency risk management and public • Develop policy, legislative and
health. For example, food systems that regulatory instruments to employ
can continue to function in emergencies whole-of-government and whole-
are essential, and a robust surveillance of-society (including private sector
system across sectors would improve such as private healthcare providers)
detection and early warning of zoonotic resources to support public health
diseases and outbreaks. This approach emergency preparedness, response
can be harnessed beyond the emergency and recovery efforts, including
response phase and mainstreamed capacity-building for future threats
into recovery and wider health system and resilient health systems and
strengthening efforts, including those communities.
conducted at subnational level.
• Advocate, mainstream and monitor
Countries must invest in institutionalizing whole-of-society approaches in
mechanisms for cross-sectoral and emergency preparedness, response
cross-disciplinary coordination and and recovery efforts through
decision-making, for use in both integrated policies, planning (e.g.
normal and emergency situations. This NHSP, NAPHS) and budgeting,
would foster a formalized multisectoral
governance culture that includes
accountability. Communities also serve
as the foundational systems for resilience.
This engagement is thus important
for community resilience, improve
trust in governments and encourage
compliance with public health and social
recommendations during emergencies
© WHO
and foster a formalized culture of
multisectoral governance and community
participation. As well as a national-levelIII. Policy recommendations and actions to build resilient communities and PHC-based health systems 17
at national and subnational the health sector, including innovative
levels. This includes dialogue with and flexible approaches to health
parliamentarians, allied ministries and service delivery and models of care.
non-State actors (trades unions, faith The pandemic has also driven research
groups, private sector entities, civil and innovation opportunities across
society, academia, etc.) to identify the life sciences, digital health, medical
sources of investment and untapped technologies, vaccine development,
technical expertise. therapeutics and diagnostics and in
self-care modalities. While much of the
• Develop health workforce capacity for current investment in research, innovation
engagement with and empowerment and learning (including the use of digital
of the population, community and platforms) is designed to support ongoing
faith groups, civil society, etc. preparedness and response and the
maintenance of safe service delivery,
• Develop mechanisms to improve
much of it may also help to make
the transmission of timely and
longer-term service delivery and risk
accurate information, and the
management more efficient and effective.
prevention, detection and response to
misinformation. Countries will need to maintain an
enabling environment to advance these
• Adapt policies and planning,
developments, while also managing the
underpinned by national legislation,
evolving risks and challenges associated
to mandate local governments’ and
with them (e.g. privacy and inequity
municipalities’ role in and support
concerns). This includes allocation of
for public health, including active
resources for research in preparedness
involvement of and participation by
and resilience; development of
local authorities.
platforms for multi-stakeholder (i.e.
• Expand cross-border and government/academia/community/
international collaborations and industry) coproduction of evidence; and
support global mechanisms to ensure strengthening of research uptake in policy
equitable access to limited products, processes.
including PPE, vaccines, diagnostics
Actionable recommendations
and therapeutics (e.g. the Access to
COVID-19 Tools (ACT) Accelerator). • Enable regulatory environments, such
as intellectual property frameworks,
5. Promote enabling and incentives and ethical
requirements for innovation, e.g. data
environments for privacy and protection.
research, innovation
• Maintain, adapt and scale
and learning
innovative models implemented
during the pandemic to facilitate
COVID-19 has required governments
continuity, access, quality, equity
worldwide to take proactive action inBuilding health systems resilience for universal health coverage and health security
18 during the COVID-19 pandemic and beyond
and utilization of health services investment cases for health in order to
while ensuring accountability and build back better and further by drawing
risk communication. These include on integrated domestic and external
digital technologies and platforms for funding and partnerships. The synergistic
health, telemedicine and the use of nature of health system strengthening
“big data” for public health through and emergency preparedness capacities
advanced data analytics and artificial is such that investment in one will benefit
intelligence. the other. Addressing foundational health
system gaps can improve health security,
• Provide regulatory support to facilitate and investing in emergency preparedness
inter- and intra-country information reduces risks and their future negative
and data-sharing and coordination and costly impact on health systems
for public health, including data and services. Countries with FCV
security and utilization of data for contexts including those under chronic
informed decision-making. Maintain economic downturn will need to have
collaborative approach with partners, special consideration in harnessing global
media and communities to address support and investment to build their
infodemics. health systems foundation and national
stewardship.
• Promote research, innovation and
learning in all-hazards emergency To support the functionality of health
risk management and health system systems and public health services,
resilience, including the use of fundamental requirements must be
knowledge to accelerate the scale-up in place, for example: functioning
of successful strategies to strengthen health information systems; adequate
PHC-based health systems in all numbers of skilled human resources
contexts, in combination with the for health; reliable and readily available
required hospital reforms. transportation, infrastructure; a scalable
supply chain and essential medicines
6. Increase domestic and equipment (e.g. PPE, diagnostics,
vaccines); financing for adequate
and global investment resourcing of the health system; and
in health system good governance mechanisms. In
foundations and all- addition, complementary essential
public goods and services, such as
hazards emergency risk universal access to water, sanitation
management and clean and sustainable energy, are
prerequisites for the provision of health
The global cost of ensuring UHC and services for the achievement of UHC
health security, as calculated by WHO, and health security. The false dichotomy
is extremely low compared with the cost between communicable and non-
of the pandemic and future threats such communicable diseases and its relation
as climate change. Long-term resilience to countries’ development status needs
needs to be factored into national to be debunked and there needs to beYou can also read
