How COVID-19 is exposing the fragility of health systems

The need to contain COVID-19 and treat those who have the disease is exposing weaknesses in health systems worldwide. This is visibly clear in the response (e.g. a lack of widespread testing, insufficient hospital capacity, equipment shortages). It is also evident – albeit less visible – in the diversion of health spending to COVID-19 at the expense of other health needs – e.g. vaccinations, routine cancer screening, maternal healthcare and gender-based violence (the latter despite a spike in rates resulting from COVID-19 lockdowns). Addressing these weaknesses will require attention to several key elements vital to health systems.

1. Spending priorities. The crisis is heightening concern over the trade-offs policymakers must make in directing health spending. What should money be spent on? How does this vary across contexts? How can budget execution (i.e. use of the budget to implement policy) be strengthened? What is the balance between spending on primary healthcare versus the tertiary health sector? Between spending on health versus other services that condition health outcomes, such as water and sanitation, education, nutrition and, in the context of COVID-19, cash transfers that enable people to stay at home.

   
   

2. Equity. The crisis is highlighting and amplifying gaps in access to quality health systems between and within countries, between "haves" and "have nots". When COVID-19 started to emerge in Kenya, for example, people with the means to do so could send samples through private labs to South Africa for testing. Poorer people had no choice but to wait for the public health system to provide tests. Issues of equity will also come to the fore once a vaccine for COVID-19 becomes available. Who will get access first? How will this be decided?

   
   

3. Left-behind groups. The crisis is showing vividly that providing quality healthcare to left-behind groups is important, not only for social justice, but also for disease containment. It is underlining vulnerabilities relating to age, gender, homelessness, economic insecurity and fragility or conflict. Safety nets can only be an effective response to epidemic and pandemic disease when they cover everyone.

   
   

4. Links between health and other sectors. The COVID-19 crisis is highlighting the links between health and other sectors. For example, close to a billion children are no longer attending schools that have closed in response to the disease outbreak, with potentially marked impacts on learning; school closures, in turn, may mean the suspension of school feeding programmes, increasing malnutrition among the children and households that depend on them (The Economist, 2020). The impact of health shocks on economies is already evident, with the International Monetary Fund (IMF) projecting that global output will fall by 3% in 2020, which also reduces the ability of governments to raise revenues (IMF, 2020). There are concrete implications for human rights, conflict and peacebuilding and social cohesion as well.

The potential the crisis offers for expanding universal health coverage

This bleak picture notwithstanding, the crisis may offer possibilities for developing health systems. ODI research exploring the experiences of 49 countries that have achieved or laid the groundwork for UHC highlights contributing factors (McDonnell et al., 2019). Three findings are particularly notable. First, 71% of these countries moved to UHC following episodes of crisis. Fragile contexts can create political appetite for UHC and disrupt powerbases that oppose it. Second, wealth is not itself a major driver of UHC; state capacity appears to be more important, alongside economic growth. This highlights the potential for all countries to build their health systems equitably and reinforces the primacy of politics. The expected post-crisis economic "bounce-back" could provide increased fiscal space for greater investments in health. Third, although progress on healthcare is generally an iterative process, once countries have established UHC they tend not to go backwards: universal systems are robust, even when facing new shocks.

Event participants offered additional reflections on the possibilities presented by the COVID-19 crisis to build more resilient health systems. For example, some high-income countries – e.g. Ireland (Turner et al., 2020), Spain (IMTJ, 2020) – have essentially nationalised the private tier of their healthcare systems to respond to the crisis, whereas in New York (Scott, 2020) rules around cost-sharing in hospitals have been adjusted to make care provision more efficient. Many African countries are waiving user fees for testing or treatment related to COVID-19 (although the retention of user fees for illnesses other than COVID-19 is undoubtedly a deterrent to seeking healthcare, even for those facing COVID-like symptoms, pointing to the need for a broader policy towards the removal of fees).

How best to capitalise upon this potential

Panellists offered several practical suggestions for using the COVID-19 crisis to mobilise resources and galvanise progress towards universal health systems, capitalising on the current political commitment to end COVID-19 and recognise the critical importance of universal systems.

Provide financing guidelines

Demonstrate the need for and cost-effectiveness of investments in primary healthcare. Panellists were united in the belief that investments in primary health are the most effective response to COVID-19. It is a mistake to think that there is a "high-tech" fix for the disease, and that the most appropriate response in poor countries is necessarily to invest in hospitals, ICU capacity and ventilators (in New York City, for example, nearly 90% of people put on ventilators died nonetheless, see Richardson et al., 2020). Rather, there is a need to look below the "tip of the iceberg" (the top 5% who are likely to need hospital care) at how health systems cater to their broader population. An exemplar is Germany, where people seek out healthcare early because there is no cost attached to doing so, and where the public health infrastructure is sufficient for widespread testing and the isolation of exposed individuals. There is a need to convince policy-makers of the tangible benefits of primary health investments (e.g. every $1 spent on vaccines saves $0.54 on other health costs).

Ensure spending is aligned with locally defined priorities, which will also minimise the scope for waste and corruption. The experience of Thailand, where the Health Intervention and Technology Assessment Program (HITAP) recommends health expenditures based on their assessments of the value for money offered by alternative interventions, is illustrative of how such a process can be institutionalised (HITAP, 2014). China, India and the Philippines are setting up similar institutions, and policy-makers are considering this option in Kenya and South Africa.

Support people's ability to hold governments to account

• Encourage public mobilisation and empowerment to foster their 'ownership' of government responses to the pandemic and their capacity to hold governments to account – e.g. through education on budget advocacy and utilisation, and supporting participation in elections for officials at all levels of government.

• Support civil society organisations, which have the potential to hold governments to account for healthcare, and to advocate for investments in health.

Foster global solidarity and multilateralism

• Highlight and amplify lessons emerging from "beacon countries" that are building their own systems and supporting other countries' investments in public healthcare and UHC – e.g. Germany, Japan, Australia, Rwanda and Ghana. The G20 and G7 can play vital roles in terms of political leadership.

• Support poorer countries through aid and debt relief. Such relief could be conditional on countries making investments in UHC and/or social health insurance, or on leaders' articulation of a new vision for healthcare provision in line with these aims.

• Ensure that health regimes are equitable – i.e. that new government agreements, surveillance arrangements and data collection do not insist on conditions that people living in poorer countries, and disadvantaged people within richer countries, cannot comply with.

• Stress the importance of health systems for global security. Much as the pandemic calls attention to the need to protect all members of a society, it also highlights the importance of extending protection to all countries. This is not just a health issue, but an issue of global security. Ensuring that it is treated as such – e.g. within the UN Security Council – can help to advance this goal.