Resilient health systems
Harvard public health professor Margaret Kruk defines health system
resilience as “the capacity of health actors, institutions, and populations
to prepare for and effectively respond to crises; maintain core functions
when a crisis hits; and, informed by lessons learned during the crisis,
reorganize if conditions require it” (Kruk and others 2015). In the face of
a crisis, a resilient health system can cope with the shock, continue to
provide services, and return to normal functioning once the crisis settles,
thereby delivering positive health outcomes in both good and bad times.
However, a health system does not function in a silo; it operates within a
socioeconomic and political context, clearly reflected by the direct and
indirect health effects of pandemics and other shocks on vulnerable
populations. A resilient post–COVID-19 health system must also address
these vulnerabilities and inequalities and sustainably respond to a range
of crises in the future.
Based on the growing literature and country experiences of Ebola and
COVID-19, we can outline five broad features of a resilient national health
system.
First, it must be vigilant.
Countries must strengthen their existing disease surveillance systems to
routinely collect and analyze information across public and private health
care in order to prevent or quell outbreaks. Several simple and effective
disease surveillance systems have been developed and adapted in
low-resource settings. For instance, in the early 1980s, virologist T.
Jacob John established a novel system in south India using a standardized
set of symptoms (which would today be called “syndromic surveillance”) to
detect and limit disease outbreaks (John and others 1998). This national
surveillance system must also incrementally build its capacity to routinely
monitor such events in neighboring countries and regions and worldwide,
which requires capacity building as well as diplomacy.
Second, it must be responsive.
Early response is a defining feature of the health systems of Germany, New
Zealand, South Korea, and Taiwan Province of China, as well as in states
such as Kerala in India—all of which have managed to control COVID-19
effectively. Responsiveness calls for preparedness, which can take years of
planning and investment, long before a pandemic hits. Singapore and Taiwan
Province of China responded to the deadly 2003 SARS outbreak with elaborate
response plans and annual drills in hospitals, while in South Korea,
following the 2015 MERS outbreak, the government invested heavily in
standard operating protocols and incentivized its biomedical companies to
research and develop rapid diagnostic tools. Countries may have emergency
preparedness plans and protocols, but these need to be aligned with
dedicated individuals and teams with decision-making autonomy to respond
swiftly, as well as with investment to strengthen the health infrastructure
and a workforce and procedures for emergency procurement and replenishment
in the event of shortages.
Third, it must be flexible and adaptable.
Hospital staff in several countries have been redeployed to COVID-19 wards.
In January and February, nearly 3,000 health workers in Cambodia were
trained and deployed to implement rapid detection and contact tracing. In
China, Fangcang shelter hospitals were rapidly set up in February
2020—large-scale venues such as stadiums and exhibition centers were
converted to temporary hospitals to isolate and care for people with mild
to moderate COVID-19 symptoms and reduce the burden on hospitals. Across
the world, hospitals have shifted some of their health services to virtual
forums such as telephone and video consultations. Such practices show the
potential of flexible use of existing resources—whether the workforce or
health care facilities—and adaptation to a rapidly changing situation.
Fourth, it is only as resilient as the communities it serves.
District public health teams must engage and involve local leaders and
community volunteers in structured roles during emergencies; extension of
roles during normal times could enhance participatory governance. In
Thailand, more than 1 million village health volunteers have monitored
communities for COVID-19. In Kerala more the 300,000 youth volunteers were
trained and deployed by the government to deliver social services to local
communities during the lockdown and support quarantined households (WHO
2020). Local leaders and volunteers are trusted in their communities, and
when district health teams partner with such stakeholders it can ensure
two-way communication and persuade communities to adopt recommended
behavior.
Fifth, and most important, resilient health systems must be equitable.
People in both rich and poor countries without effective health coverage
have struggled to get tested and seek timely treatment for COVID-19 and
other health emergencies. Universal health coverage, regardless of
socioeconomic status, geographic location, gender, age, or preexisting
conditions, is needed now more than ever (WHO 2010). Countries must invest
in universal health coverage, particularly by expanding health insurance
coverage and strengthening primary health care services, to ensure early
detection and response to COVID-19 and other infectious diseases. This will
prevent secondary and tertiary health facilities from being overburdened
and disrupting the delivery of other essential health services. Most
important, universal health coverage will keep families from falling into
poverty during such public health emergencies.
