The novel coronavirus pandemic has exposed the fault lines in both global and national health infrastructures, highlighting inequalities and structural flaws. There has never been a timelier moment to focus on how to improve the resilience of health systems
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The covid-19 pandemic has already transformed the world as we know it, upending policy priorities across multiple sectors. Comprehensive changes in healthcare systems, healthcare funding and approaches to public health more broadly are more likely than not. The specific changes required in each area will shape policy-making and open the door for accelerating efforts to reverse the growth in non-communicable diseases (NCDs) around the world. Those already living with NCDs have been, and continue to be, more susceptible to the virus and having contracted it may be left with longer-lasting side effects. In addition, the single mindedness of researchers trying to find treatments and vaccines for covid-19 is likely to mean fewer resources available in the short-term for other health needs. In hard hit parts of both developed and developing economies, many patients are likely to experience interruptions in the management of their NCDs. At the same time, the global impact of the pandemic and the need for collaboration to find solutions, could suggest a blueprint for how to redesign public health infrastructure to better respond to both infectious diseases and NCDs. One of the key lessons to come out of the covid-19 crisis so far—and one with enormous ramifications for the approach to NCDs in future—is the need for health systems that are more flexible. “Generally the performance of health systems has been underwhelming, if not catastrophic,” says Rifat Atun, a professor of global health systems at Harvard University’s T.H. Chan School of Public Health. “Even in systems we thought of as being high performing, such as Spain, the UK and Italy, the performance hasn’t been so optimal.” Another lesson is the importance of access to health care. In many developing countries in Africa and Asia there is no universal health coverage. Notably, the same is true for America, the world’s wealthiest country. Without decent health care for all, populations in these countries were already less healthy going into the pandemic and have struggled to deal with the impact of covid-19. In its aftermath, medical professionals are likely to struggle to treat those whose conditions have worsened or have been poorly managed during the crisis. Many countries will also need to look at reworking service delivery to provide the coordinated care that is crucial to manage NCDs. Better sharing of information by public health agencies will be a likely requirement for improving health services.
What have we learned
Covid-19 has had an especially severe effect on those with NCDs. They are more vulnerable to developing serious cases of the virus. A report released in June by the main public health agency in the US, Centers for Disease Control and Prevention (CDC), found that those with NCDs were hospitalised six times as often as healthy individuals infected with covid-19 during the first four months of the pandemic and were twelve times as likely to die. As response to the outbreak has disproportionately monopolised the time and resources of healthcare providers, public health campaigns and day-to-day management of NCDs has been overshadowed. In some cases, progress towards addressing chronic illnesses may even have been reversed. In many developed economies there is concern that cancer cases have been missed or left too late for successful treatment due to the pressure on health systems. In developing countries that were only beginning to introduce some cancer screening programmes, the setback in progress is likely to be magnified. Mental health is also a rising concern. Across the world, people in long periods of isolation are boosting the number of those with mental health issues. The UK National Health Service, which has battled the worst covid-19 outbreak in Europe, has been particularly affected, according to Allyson Pollock, a consultant in public health medicine and director of the Newcastle University Centre for Excellence in Regulatory Science. “It’s been a covid-only service for the last few months, which means that there is a huge backlog for other care,” she says. The economic dislocation caused by the corona- virus is likely to have wide-ranging consequences that could reduce the funding available for promoting good health. A sustained recession or depression is likely to disproportionately affect public health funding, especially in developing countries. Lack of adequate financial resources will have an impact on health campaigns, especially those related to NCDs (such as anti-smoking, anti-obesity) and on screening programmes designed to flag people with chronic conditions. Unemployment and other hardships associated with an economic downturn could make patients with NCDs less willing or able to adhere to medical and lifestyle regimes. A more specific dislocation will affect hospitals in countries such as the US with private healthcare systems and professionals that depend on income from surgery and elective procedures, many of which will have lost money during the pandemic. With fewer healthcare resources, policymakers will need to determine how to make the most of them. In July, Takeshi Kusai, the World Health Organization’s (WHO) Regional Director for the Western Pacific region, said, “We can grow a new future where health is recognised as an investment. Where healthy people reach their full potential and inequalities are minimised. This new future is the dividend of covid-19 that the WHO hopes for.”
Generally, the performance of health systems has been underwhelming, if not catastrophic
Balanced governance
The reality of the novel coronavirus on the ground has highlighted many of the aspects that make global coordination of health initiatives so difficult: competition for health resources such as personal protective equipment (PPE) and ventilators; the politicisation of policymaking; and growing xenophobia in some quarters. Proper public health leadership requires governments to get the balance right between centralised and local control of services and surveillance. The pandemic crisis in the US has highlighted the problems of a health system without strong direction from the central government. States have competed for scarce PPE and received contradictory guidance on testing and tracing programmes. The CDC has appeared to be tentative and ineffective, leaving a vacuum where coordinated efforts to contain the pandemic should have been. In the UK, by contrast, reforms under the previous Conservative government moved responsibility for public health away from regional strategic health authorities, which had been abolished, to local governments, effectively disconnecting it from the National Health Service (NHS). At the same time a new national body, Public Health England (PHE), was created. The result was a public health system that was fragmented and slow to respond. By contrast, some of the countries that have been most widely praised for their ability to track and contain local outbreaks, including Germany and South Korea, have health systems that have been able to move quickly on the national and local level. Elsewhere in Europe and Asia, variations in the way governments have used current scientific understanding have led to radically different policies toward social distancing, use of masks and length of lockdowns. Ultimately, as the search for a vaccine and cross-border research efforts demonstrate, the best way of fighting both covid-19 and NCDs is through international efforts and cooperation across both governments and non-governmental organisations.
Lessons in data sharing
Lessons can be learned from the rapid collection and sharing of data achieved during the pandemic. As covid-19 developed into a global pandemic, the political will existed to not only gather but also share the collected data. The same approach to data on NCDs would enable continued dissemination of “best buy” solutions and provide better understanding of what works. “My hope is that for anyone either working on the research side or funding research, that covid-19 drives us as a medical community to be more collaborative, whether between NCD and infectious disease folks or global disease and national disease policymakers,” says Celina Gorre, chief executive of WomenHeart, the US National Coalition for Women with Heart Disease and former executive director of the Global Alliance for Chronic Diseases. “The system we have only leads to silos and duplication.” Investment is also critical. A spring report by the WHO, under its Build Back Better campaign, called on governments to build bridges between national humanitarian emergency plans and NCD responses to allow for continuity in NCD treatment. WHO also called for the prevention, early diagnosis, screening and appropriate treatment of NCDs to be included in essential primary health services and universal healthcare benefit packages. International donors and policymakers in developing countries may look to apply some of the lessons they have learned from covid-19 and other pandemics to broader public health infrastructure reforms. The WHO report advocates, “New international funding patterns, a reset of global initiatives and the building of new partnerships for NCDs.” The African Business Magazine earlier this spring predicted renewed commitment to upgrading the continent’s fraying public healthcare systems in the wake of the virus and observed that Sierra Leone, Guinea and Liberia all bene- fitted from government efforts to reinforce their “operational, epidemiological and logistical capabilities,” in the aftermath of the 2014-15 Ebola crisis. The need for better access to healthcare is a specific funding priority that is likely to move to the top of the public health agenda. “Clearly, countries that have universal health coverage, where individuals do not have to concern themselves with excess payments, are doing relatively well and have better protection,” Atun says. Former UK Health Minister and current director of Imperial College London’s Institute of Global Health Innovation, Lord Ara Darzi, recently pointed out that many modern health systems operate as “sickness services” rather than “health and well-being services.” Noting that diabetes, obesity and cardiovascular disease are also pandemics, Darzi said prevention of NCDs must be addressed with the same urgency as treatment.
We can grow a new future where health is recognised as an investment. Where healthy people reach their full potential and inequalities are minimised
Flexibility is key
The immense variation in rates of covid-19 around the world have highlighted gaps in healthcare provision and weaknesses in healthcare systems—principally problems with workforce management and healthcare delivery that have made it difficult to control NCDs or react quickly to a pandemic. “Covid unmasked many of the inefficiencies, supply systems broke down, and there was no continuity of care as many countries couldn’t repurpose systems,” Harvard’s Atun says. Even countries with adequate funding in hospital settings frequently did not have enough staff resources in public health surveillance or primary health care, he noted, a problem that must be resolved to successfully treat and pre- vent NCDs in future. Notably, two countries that have often been criticized for relative health inefficiencies and excess hospital capacity, Japan and Germany, found these to be advantages in the pandemic. The extra capacity was put to use relatively quickly as was the implementation of systems to scale up testing for the virus. By comparison, many other countries struggled to respond to the virus surge. Better coordination and more nimble allocation of services could also be applied to NCDs: once “hotspots” of cardiovascular or respiratory dis- ease are identified, resources can be channelled more quickly into preventative and primary care. Health workforce pressures during the pandemic have increasingly been alleviated by a radical scaling up of telemedicine, which has served the dual purpose of continuing some non-covid health services at a safe distance. Technology is likely to play a much more substantial role in the management of chronic conditions, both through greater use of telemedicine and through remote systems for monitoring blood pressure or testing blood sugars in a home setting. Inequalities in internet access, however, would be further highlighted. Gaps in service delivery have been particularly obvious as countries around the world have struggled to mount a fully integrated response to covid-19, Atun observed. “Patients were looked after in hospital, but up- stream, in care homes and communities, they were not well managed, so many people presented late and outcomes were worse than they could have been,” he says, adding that Latin America has been especially hard hit. “All of this has implications for chronic dis- ease, as you need highly personalised centres, with continuity of care. The system has to function as a system to manage the individual, not just one symptom at a time.” Atun worries that after the emergency response to covid-19, health systems will return to their old practices. The risk is higher for developed countries with “sclerotic” systems. By contrast, developing countries with fewer legacy systems will find the transformation easier. “We need health systems to become more responsive, agile and resilient,” he adds. “We must take the opportunity to change.
TEXT Andrea Chipman — PHOTO Jeremy Stenuit