Building health systemsresilience for universal

health coverage andhealth security

during the COVID-19pandemic and

beyond

A BRIEF ON THE WHO POSITION

WORLD HEALTH ORGANIZATION20 Avenue AppiaCH-1211 Geneva 27Switzerland

https://www.who.int/

Building health systemsresilience for universalhealth coverage andhealth securityduring the COVID-19pandemic andbeyond

A BRIEF ON THE WHO POSITION

WHO/UHL/PHC-SP/2021.02

© World Health Organization 2021

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This position paper was developed through collaboration between headquarters and all regional offices of WHO,

under the leadership of Zsuzsanna Jakab (Deputy Director-General, WHO) and Mike Ryan (Executive Director, WHO Health Emergencies Programme) with further guidance from Jaouad Mahjour (Assistant Director-General, Emergency Preparedness, WHO).

The responsible technical and coordination team comprised Sohel Saikat, Marc Ho, Dheepa Rajan and Andre Griekspoor and was led by Suraya Dalil, Stella Chungong and Gerard Schmets.

At the regional level, leadership and coordinated contributions were provided by directors and leads responsible for programme management, universal health coverage and life course, and health emergencies: Natasha Azzopardi-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.

Reviewers and contributors from WHO headquarters and regional offices: Pascale Abie, Hala Abou Taleb, Benedetta Allegranzi, Sophie Amet, Roberta Andraghetti, Ali Ardalan, Ian Askew, Anshu Banerjee, Anil Bhola, James Campbell, Alessandro Cassini, Jorge Castilla, Ogochukwu Chukwujekwu, Giorgio Cometto, Peter Cowley, Sofia Dambri, Neelam Dhingra-Kumar, Khassoum Diallo, Abdul Ghaffar, Ann-Lise Guisset, Lynne Harrop, Qudsia Huda, Humphrey Karamagi, Masaya Kato, Rania Kawar, Edward Kelley, Devora Kestel, Hala Khudari, Joseph Kutzin, Yue Liu, Mwelecele Malecela, Paul Marsden, Robert Marten, Nikon Meru, Hernan Montenegro Von Mühlenbrock, Saqif Mustafa, Matthew Neilson, Hyppolite Ntembwa, Denis Porignon, Adrienne Rashford, Tomas Roubal, Cris Scotter, Redda Seifeldin, Kabir Sheikh, Zubin Shroff, Ian Smith, Rajesh Sreedharan, Shamsuzzoha Syed, Regina Titi-Ofei, Anthony Twyman, Jun Xing, Kenza Zerrou, Yu Zhang, Zandile Zibwowa.

Acknowledgements

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Key Messages For Heads of Government, Ministries of Finance and Leaders Outside the Health Sector

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• The health of populations is key to economic development – a fact recognized since the seminal World Bank report of 1993, Investing in health (1).

• The catastrophic human, social and economic toll of COVID-19 has demonstrated that protecting health is also critical for economic security; just as economic development and health development are inextricably linked, so too economic resilience depends on resilient health systems.

• Governments have invested heavily in the COVID-19 response, and now face the challenge of fiscal pressures, managing heavy debt burdens with pressure to increase taxation and reduce spending, while sustaining social protection.

• Governments must avoid falling into the cycle of “panic then forget”, frequently observed in past pandemics. Increased investment in emergency preparedness and response has all too often been followed by rapid disinvestment and neglect, which weaken health systems and undermine economic resilience.

• Many countries will require substantial health system reforms, addressing foundational gaps in public health capacities, including the International Health Regulations (IHR) (2005), to make them more efficient, effective and resilient, ensure economic resilience and socioeconomic development, and build trust.

• These reforms must integrate health emergency preparedness and response systems into universal health coverage efforts, based on primary health care and essential public health function approaches, with a reorientation of investment and resources.

• National health security and economic stability are also dependent on the protection of populations living in contexts of fragility, conflict and violence. Governments must therefore ensure dignified, equitable health services for marginalized and vulnerable populations during and beyond emergencies.

• Such reforms, which build all-hazards health emergency preparedness and resilient health systems, generate a substantial return on investment in terms of healthier populations, economic resilience and equitable social development.

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Key Messages for Health Leaders, Partners and Communities

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• The COVID-19 pandemic and its catastrophic human, social and economic toll have demonstrated that making the health system resilient to achieve universal health coverage and health security must be a priority for every WHO Member State. Universal health coverage and health security are two sides of the same coin and interdependent.

• Making a national health system resilient requires: a high-performing health system oriented to primary health care; the ability to sustain essential health services for all, even during an emergency response; and investment in the essential public health functions, with emergency risk management for sustainable IHR (2005) capacities.

• Adequate investment in health emergency preparedness ensures that countries have the capacities to prevent, detect and respond to future health threats and emergencies.

• Making health systems resilient and ready to address future threats requires substantial heath system reform in countries; this should be backed up by a reorientation of investments and resources.

• In view of the considerable damage that public health threats can inflict on national economies and population well-being, every WHO Member State Government should consider action to:

i Including IHR 2005; the Sendai Framework for Disaster Risk Reduction, Paris Agreement on Climate Change and the SDGs

• increase and sustain adequate investment for health (including the health system foundations and emergency preparedness and risk management) and position health as central to socioeconomic recovery and development;

• build a strong primary health care foundation as the most cost-efficient and equitable way to achieve universal health coverage and health security;

• invest in essential public health functions for holistic and sustainable public health capacities at all levels of health systems, including capacities required for all-hazards emergency risk management;

• integrate health security, emergency preparedness and risk management requirementsi in health system strengthening efforts, and vice versa;

• invest in whole-of-society governance with meaningful engagement of communities, and civil societies, the private sector and all line ministries;

• pay special attention to those who are disproportionally affected by health emergencies, for example, people in countries with contexts of fragility, conflict and violence, as well as vulnerable and marginalized groups in all countries, including migrants and refugees.

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IntroductionThe widespread health and socioeconomic impact of the pandemic of coronavirus disease (COVID-19) on all aspects

of society is by now well-documented (2, 3). Besides overall setbacks in progress made in achieving Sustainable Development Goal (SDG) 3 (Ensure healthy lives and promote well-being for all at all ages), the protracted disruption of essential health services is threatening future health outcomes in many places (4). This comes on top of the struggle of many countries to meet the increased demands imposed by the pandemic and conduct essential associated public health functions such as contact-tracing, quarantine and isolation. Some countries have faced concurrent health emergencies. Furthermore, new barriers to health care demand, such as restrictions on movement, reduced ability to pay and fear of infection, still pose major challenges for health service utilization more than one year on from the start of the pandemic. This is the case despite the many innovative approaches which countries have adopted to reduce disruption. One of the world’s biggest challenges in this crisis of unprecedented proportions, as has been seen in other health emergencies, remains its hugely inequitable impact on vulnerable populations and communities, both within and between countries.

The pre-existing inequalities causing COVID-19’s disproportionate effect on both fragile countries and fragile populations brings to the fore the need

for both robust health systems and health emergency preparedness. Health security cannot depend only on discrete preparedness and response functions; it also relies on a high-performing health system, which can be drawn upon for surge capacities without compromising necessary services. Resilience relies on a system which constantly strives to reach health system goals – service access, quality, effectiveness and financial protection, among others (5) – even during times of crisis and sudden increases in health needs. At the same time, resilience also implies that action to achieve these health system goals is more strongly underpinned by emergency preparedness and all-hazards risk management perspectives.

Health systems resilience is “the ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management” (6). Health system resilience thus requires the capacity to prevent, detect, respond to and recover from public health threats and emergencies and the agility to deploy resources to meet the greatest needs and maintain essential health services through crisis periods.

Objectives

Since universal health coverage and health security are complementary goals, this position paper provides a rationale and recommendations for

Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond2

building resilience and seeking integration between promoting universal health coverage and ensuring health security by the following means:

• recovery and transformation of national health systems through investment in the essential public health functions and the foundations of the health system, with a focus on primary health care and the incorporation of health security requirements;

• all-hazards emergency risk management, to ensure and accelerate sustainable implementation of the International Health Regulations (IHR) (2005) and health emergency preparedness;

• a whole-of-government approach to ensure community engagement and whole-of-society involvement.

This brief calls for a renewed and heightened national and global commitment to make health systems resilient against all forms of public health threats for sustained progress towards universal health coverage, health security (including implementation of IHR (2005)) and the SDGs.

Universal health coverage and health security: two sides of the same coin

Universal health coverage and health security are interdependent and complementary health goals, and a strong

and resilient health system provides the foundation for both. Health systems built on a multisectoral, whole-of-society approach are key to effective management of all types of hazards. They enable existing capacities to address increased health needs and underlying risks, ensure sustained delivery of high-quality, safe essential health services even during disasters and emergencies, and build back better through the recovery period, making use of the lessons learned. This requires proactive, system-wide integration of universal health coverage and health security efforts at all levels of governance (national, subnational and community).

The COVID-19 experience has shown that critical health systems gaps and vulnerabilities exist in countries from all income groups. Reacting to health emergencies as they occur, instead of ensuring long-term health emergency preparedness-building for health systems resilience, has meant that countries were unprepared for an emergency of the speed, scale and severity of the COVID-19 pandemic. It has also shown that emergency preparedness and response cannot be disentangled

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from other aspects of public health – leadership, community engagement, coordination mechanisms, action to address inequalities, health care and health promotion. It has also shown up market failures with regards to production and allocation of essential supplies and vaccines. Vertical investment and programming within the health sector and across sectors have proven ineffective in enabling long-term health systems development and resilience. Health systems capacity for effective response has also been hampered by ad-hoc and fragmented global cooperation and coordination in the context of surveillance, flexible and deployable human resources and equitable access to infection prevention and control supplies and safe and effective medical products.

The world has a window of opportunity to learn from the COVID-19 pandemic and build back better to create integrated approaches for universal health coverage and health security at an accelerated pace.

Primary health care and the essential public health functions as a foundation for universal health coverage and health security

A primary health care orientation in health systems, and the systematic integration of emergency risk

management within them, can provide the essential foundations for both universal health coverage and health security. The three key primary health care components of the Vision for primary health care in the 21st century – integrated health services including essential public health functions; multisectoral policy and action; and empowered people and communities (7) – are key levers where action is needed to achieve both goals. For example, integrated health services offer a continuum of care across different sites and levels and according to population need (8). This also requires more explicit integration of risk management approaches, including anticipating surge capacity for acute emergency services, in addition to well laid preparedness plans to ensure continuity of essential services with adequate safety for staff and patients in times of crisis (9). A multisectoral approach is necessary to address public

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Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond4

health hazards beyond infectious disease outbreaks effectively, such as industrial pollution, unsafe food or radiological events; it is also the only way to address the social determinants of health more broadly as an integral component of health systems strengthening in a way that also reduces risks for emergencies. Empowering communities implies health governance with a whole-of-society mindset, where people’s voices, including those of vulnerable and marginalized populations, are systematically amplified through institutionalized participation mechanisms which can be used in the service of both emergency response and day-to-day health sector operations (10).

The essential public health functionsii include surveillance, governance arrangements, financing, health promotion and risk reduction, health legislation, public health research and human resources (11). These functions are necessary to underpin strong primary health care; action in these areas ensures that both health systems strengthening and all-hazards emergency risk management also serve as means of achieving universal health coverage and health security (12, 13).

Despite this inherent interdependence and overlap in the actions needed to achieve resilience, the approach to date at both global and national levels has

ii The essential public health functions are a list of minimum requirements for Member States to ensure public health. These focus on health promotion, prevention, determinants and security. They include aspects such as surveillance and monitoring, public health workforce, governance, regulation and public health legislation, public health systems planning and management, public health research, social mobilization and participation, preparation and response to health hazards and emergencies and promotion of health and health equity. The essential public health functions have recently been referred to, from an economic perspective, as “common goods for health”. See: Common goods for health. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/health-topics/common-goods-for-health#tab=tab_3, accessed 24 June 2021).

been fragmented (14), resulting in historic and ongoing underinvestment in primary health care and the essential public health functions. The COVID-19 experience has starkly revealed the vulnerabilities brought about by that underinvestment, regardless of the income group of the country concerned. Even countries considered to have strong IHR (2005) capacities and/or strong health systems could not always fall back on sufficiently robust public health and/or primary health care capacity (15) with effective governance. The need to prioritize primary health care and essential public health functions has thus never been more acute.

Cost should not be a barrier

The cost of ensuring universal health coverage and health security is extremely low compared with the cost of a crisis

such as the current pandemic or future threats, including climate change (1, 16, 17, 18, 19). Further estimates concur that improving emergency preparedness is very affordable, with estimates ranging from US$ 1 to US$ 5 per person per year (20) – which will pay for itself several

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times over because of the significantly lower costs incurred when emergencies do happen. Moreover, a 1% additional allocation of gross domestic product to primary health care will enable most countries to bridge current coverage gaps (21). This means that financial cost should not be a barrier that prevents countries from investing in building resilience; in the end, the dividends gained by addressing universal health coverage and health security simultaneously leave us collectively better off, making it a wise investment from both a financial and a health and well-being point of view.

Policy recommendations

WHO calls on countries to take action for recovery and transformation of their national and subnational health systems and

proposes the following interconnected policy recommendations and actions to inform planning, investment and interventions by all relevant stakeholdersiii. When implementing these recommendations, countries should apply an integrated approach, taking into consideration the heterogeneity within and between countries, and the complementarity between the various concepts covered.

iii A more detailed version of the recommendations and actions is contained in the WHO position paper Building health system resilience towards universal health coverage and health security during COVID-19 and beyond.

1. Leverage the current response to strengthen preparedness against future threats and health systems towards resilience. This involves using the results of multisectoral reviews and intra-action and after-action reviews to inform sustained investment in emergency preparedness, the IHR (2005) capacities and their functionality, determining priority needs, and embedding policies and national plans of action for health security in health system strengthening. It ensures population access to quality health services while maintaining capacities for emergency preparedness. It includes harnessing investment for medium- to long-term recovery, preparedness and resilience against all types of hazards. Implementation of IHR (2005) must remain a requirement for health systems resilience.

2. Invest in essential public health functions at all levels of health systems, including those needed for all-hazards emergency risk management. Critical and chronic gaps in essential public health functions should be the target of intensified investment.

3. Build a strong primary health care foundation by ensuring political commitment and leadership to place primary health care at the heart of efforts to attain universal health coverage, health security and the SDGs.

Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond6

4. Invest in institutionalized mechanisms for whole-of-society engagement. Long-term commitment will be required to bring about a real shift in the modus operandi of emergency preparedness, emergency risk management and maintenance of essential health services, which are essential for functional health systems and public health operations with more inclusive participation.

5. Create and promote enabling environments for research, innovation and learning by finding ways to maintain and adapt the innovative models implemented during the pandemic, thereby increasing the ability to handle the demands of future threats and emergencies.

6. Increase domestic and global investment in health systems foundations and all-hazards emergency risk management: this includes prioritizing investment and financing for public health and health security, with consideration for countries with protracted instability and fragile systems.

7. Address pre-existing inequities and the disproportionate impact of COVID-19 on marginalized and vulnerable populations by, for example, monitoring inequities in health and access to care, using

iv Access to COVID-19 Tools (ACT) Accelerator; United Nations framework for the immediate socio-economic response to COVID19; SDGs; IHR (2005); the Sendai Framework for Disaster Risk Reduction; Paris Agreement on climate change, Universal Health Preparedness Review.

disaggregated data, to inform policies, planning and investment globally, with a focus on marginalized and vulnerable populations within and beyond countries with fragile, conflict-affected and vulnerable (FCV) settings.

Enabling implementation with shared responsibility

The above recommendations highlight the need for coordinated, multisectoral, whole-of-

society action with clear government ownership.

WHO will collaborate with its Member States, the United Nations and other partners to ensure synergies with existing and upcoming national and global effortsiv. At national level, WHO and its partners will similarly support bolstering whole-of-society, government-led socioeconomic recovery and transformation processes. This will include support for bringing together various line ministries, development partners, civil society, the private sector and communities to promote the health agenda and mobilize resources for a primary health care oriented path towards universal health coverage and health

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security. WHO will advocate for and highlight the key roles of all stakeholders in ensuring increased investment for health as a priority development agenda across various sectors.

An intensified focus on vulnerable and marginalized populations in all countries, and especially in FCV settings, is necessary to address the vast global and intra-country inequalities exposed by the pandemic. WHO is committed to working with Member States and partners to support countries with FCV settings in addressing critical foundational health systems issues and operationalizing the humanitarian-development-peace nexus.

The expected result of such a series of actions and commitments is health systems which are more resilient to future shocks in terms of maintaining quality essential health services with financial protection while ensuring that governments and communities are better prepared to prevent, detect, manage and respond to health threats, including providing scalable surge capacity to meet health emergency needs.

The aim is thus to avoid a repeat of the challenges and gaps of the past and ongoing emergency experiences, including the lack of adequate investment

in health systems recovery and building resilience and better preparedness following emergency response efforts. This will only happen if all sectors collaboratively position health as central to national development.

This brief provides a succinct, policy-oriented summary of the WHO position paper on building health system resilience during COVID-19 and beyond, developed in consultation with WHO regional offices and headquarters. The policy implications and recommended actions are targeted at a broad audience of policy-makers with a view to their ongoing role in the COVID-19 response, health systems strengthening, health and socioeconomic recovery and national development.

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Building health systemsresilience for universal

health coverage andhealth security

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A BRIEF ON THE WHO POSITION

WORLD HEALTH ORGANIZATION20 Avenue AppiaCH-1211 Geneva 27Switzerland

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