Fighting infectious disease, supporting health workers, delivering social services, and protecting livelihoods have moved to the very center of the world’s attention. Covid-19 pandemic has proved to be a severe moment of truth for health systems around the world. In some places, it has exposed weaknesses and gaps—shortages of critical supplies, underinvestment in public health infrastructure, and a lack of coordination and agility among policymakers, political authorities, and health care leaders—which have led to overwhelmed health systems, rapid growth in cases, and high mortality. We believe that all health systems should learn a lot from this pandemic about the way to fight any disease and manage the overall population health of their citizens. Here are we report some considerations on what health systems around the world can learn from Covid-19 pandemic.
Investing in strengthening public health systems
While the fight against Covid-19 is still ongoing and is requiring great deal effort and coordination by national governments, it is clear that the outbreak will have a lasting impact on health investments for many years to come. Health is the second largest area of public expenditure for most countries; as a consequence, it is in the financial spotlight. At the same time, there is upward pressure from the rising costs of technologies and pharmaceuticals and – to a lesser extent – from ageing populations. Since many years, austerity measures and wage bill caps imposed by international financing institutions have stalled investment in the health workforce, triggered recruitment freezes and drastically reduced the number of health jobs. This, combined with poor working conditions, has also led large numbers of health workers choosing to leave the public sector or even their home country to work in more prosperous settings. As a result, many countries do not have enough resources to train, deploy and sustain a health workforce to meet the community needs. The Covid-19 pandemic has demonstrated that sufficient public funding to ensure a comprehensive response to health is required. Reprioritizing public spending toward bolstering the health systems requires action from good government leaders. Every country should develop specific processes for allocating budget funds to health.
Investing in prevention
Prevention can be the most cost-effective way to maintain the health of the population in a sustainable manner, and creating healthy populations benefits everyone. Concerns about upfront costs and the intangibility of outcomes, however, too frequently lead to a lack of action and continued investment in increasingly expensive curative approaches. It is well demonstrated that vaccinations and screening programmes are largely cost-effective. Population-level approaches are estimated to cost on average five times less than individual interventions. The Covid-19 pandemic has had an immense impact on public and healthcare understanding of infection prevention and control. Throughout the world people and health workers are practicing improved hand-washing techniques and social distancing, and other intervention measures to prevent infections. The ongoing Covid-19 pandemic is a reminder of the importance of vaccination. We already know that as a public-health intervention, vaccination is one of the most impactful and cost-effective. It has eradicated smallpox, nearly eradicated polio and, in recent decades, reduced the incidence of infectious diseases that once killed millions every year, such as measles, helping to halve child mortality. It is now accepted that the only way to end Covid-19 pandemic, minimize loss of life and return to some semblance of normality is through vaccination. However, vaccine development is a lengthy, expensive process. Attrition is high, and it typically takes multiple candidates and many years to produce a licensed vaccine. Because of the cost and high failure rates, developers typically follow a linear sequence of steps, with multiple pauses for data analysis or manufacturing-process checks. Developing a vaccine quickly requires a new pandemic paradigm, with a fast start and many steps executed in parallel before confirming a successful outcome of another step, hence resulting in elevated financial risk. In this context health systems will have to invest! For the moment, however, we will just have to wait and health systems will have to do everything to protect people until Covid-19 vaccines are shown to be effective, produced in unprecedented quantities, and make sure that everyone has equal access to them. We are not safe unless everyone is safe. Otherwise, this virus will keep coming back.
Looking at healthcare from a global perspective
Since the rise of globalisation, the world has become more closely connected and people can easily interact with each other without facing any serious barriers. The free movement of people, goods, and services brought about by globalisation has stimulated socio-economic development, but it has also become a channel for the spread of diseases. The cure for Covid-19 is yet to be found, and its impact—in terms of infected people and deaths—is continuing to grow around the world. In recent months there have been an explosion of research activities and clinical trials to find a cure and a vaccine for Covid-19. Most of these activities occur on a local level. However, at the same time, there is a need for coordination of international efforts and the formulation of a common global sharing.
It’s clear that there is no better time than now to start really looking at healthcare from a global perspective. In our countries we need to study what other countries have done, how they have combated Covid-19, where they have been successful, and where they could have done better. This type of analysis has helped, all people around the world, tackle Covid-19 more effectively. At the same time, a global sharing of research and studies will be necessary to have safe treatments and, above all, a safe vaccine as soon as possible. The global nature of Covid-19 has called for a global response, both in the geographic sense and across the whole range of sectors involved. Nobody has been exempt from the problem!
Covid-19 can be an opportunity to look at healthcare from a global perspective. This much is certain; we’re connected. We have all the power in the world to talk to each other—distance, language, geography offer no barriers—and yet we don’t take advantage of it.
Supporting a “Global Health” approach
In the last twenty years, several viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 to 2003, and H1N1 influenza in 2009, have been recorded. Most recently, the Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia in 2012. In a timeline that reaches the present day, an epidemic of cases with unexplained low respiratory infections detected in Wuhan, the largest metropolitan area in China’s Hubei province, was first reported to the WHO Country Office in China, on December 31, 2019. According to the first genetic analyses of SARS-CoV2, the virus originating in a bat required an intermediate host to acquire, through recombination and mutation, the capacity to infect humans. Among the possibilities identified in the search for the intermediate host: the pangolin, a heavily poached endangered species. This type of virus transmission is possible, but rare. However, in recent years, interactions between areas occupied by humans and natural areas have accelerated. The destruction and fragmentation of the habitats of certain species, their farming, and their illegal trafficking all increase health risks. In addition to the anthropization of areas (urbanization, transport, mining, etc.), the industrialization of agriculture, food production and livestock farming – with, in particular, the intensive use of antibiotics creating resistance in bacteria –, are also implicated in the multiplication of infectious diseases incidents and the creation of conditions conducive to their globalization. To manage the ongoing crisis and to better anticipate the next one, it is needed to strengthen the foundations of an ecology of health, focusing on the interdependencies between the functioning of ecosystems, sociocultural practices and the health of human, animal and plant populations taken together. Covid-19 is a recent example of the complex threats of emerging infectious diseases. Emerging infections in humans and animals, along with other threats such as antimicrobial resistance, are difficult challenges to humanity, to a large extent driven by increasing food production and other issues related to a growing and more resource-demanding population. The interdisciplinary “One Health “approach represents an attempt to deal with such complex problems engaging professionals from many disciplines such as human, veterinary, and environmental health, as well as social sciences. The “One Health” approach recognizes the interrelationship between animals, humans and the environment and encourages collaborative efforts to improve the health of people and animals, including pets, livestock, and wildlife.
Ensuring preparedness for disasters like Covid-19
Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. A large amount of patients have been suffering from Covid-19 presenting to the attention of the medical personnel inside and outside the hospitals.
In some locations, almost 10% of cases have presented with severe respiratory impairment necessitating of intensive care. Despite intensive life support, however, many of the sick have died of this new respiratory viral infection. Beyond fatalities, a greater percentage have necessitated admission to hospitals for diagnosis and treatment. Health systems of different parts of the world have been in great troubles, and some of them have been at risk of collapsing under this infectious emergency due to discrepancies between system resilience and an overwhelming number of patients requiring attention. Evaluating how it has evolved, Covid-19 would have deserved consideration as a mass casualty incident (MCI) of the highest nature. Generally, a MCI conjures up imagery linked to a scene of catastrophic and impressive events either natural or man-made. This typically involves patients who are severely injured, bleeding, and screaming, brought to the hospital by emergency services. This is not what the Covid-19 pandemic looked like. However, Covid-19 must be considered as a MCI. A mass casualty incident is defined as an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time. It requires exceptional emergency arrangements and additional or extraordinary assistance. It affects more and more people, disrupting health sector programmes and essential services, and slowing the process of sustainable human development. Many lives can be saved if the affected communities are better prepared, with an organized scalable response system already in place. Preparedness is the key to mitigating a disaster. There are two aspects to consider when it comes to being prepared for a healthcare emergency:
Disaster management drills
To ensure preparedness for disasters like Covid-19, the onus falls on the health systems to design disaster management drills that cover multiple emergency scenarios. However, disaster management drills cannot be limited to individual hospitals. During this crisis, many countries failed to find a proper collaboration model between local and national levels. The common gaps in health system preparedness around the world are generally well understood, but they are often not addressed in a comprehensive and systematic way. In particular, many countries have not yet developed mass casualty management plans, and communities are too often left alone to develop preparedness and response plans without guidance from higher levels. The lack of effective national action plans has impacted considerably the consequences of this epidemic.The action plans have progressively followed during the pandemic. Probably, well-structured action plans aimed at containing a potential disaster would have created fewer difficulties in managing Covid-19. Moreover, Covid-19 showed how interconnected and interdependent our world has become: there is no way of tackling an health crisis such as a pandemic or antimicrobial resistance at national levels only. Covid-19 illustrated our health systems vulnerability, across borders, beyond North-South, East-West, public-private divides, and the limits of our segmented approach to development. In this context a continuous collaboration with international agencies is essential. In recent weeks, the World Health Organization (WHO) has been accused of mismanaging the Covid-19 epidemic.
The international agency has certainly come in for its share of criticism, and some of it is warranted. The international agency has certainly come in for its share of criticism, and some of it is warranted. The WHO was slow to publicly recognize the scale of the threat posed by the outbreak in China. Though the organization declared the virus a global health emergency in January, its Director-General didn’t begin characterizing it as a pandemic until March 11, when the virus had already been confirmed in at least 114 countries. In part, that’s probably because, like most large bureaucracies, the WHO is a cautious institution, and probably it did not want to generate excessive panic. However, WHO has continued to play an indispensable role during the current Covid-19 outbreak. During this pandemic WHO has worked 24/7 to analyse data, provide advice, coordinate with partners, help countries prepare, increase supplies and manage expert networks.WHO manages to support national health plans and emergency responses in more than 150 countries with an annual global budget smaller than that of a great hospital system. It is also the only organization in the world with the infrastructure and ability to identify emerging diseases, as it did with Covid-19 and every major health threat in modern history.
Flexibility of infrastructure and staff
Another aspect of preparedness is how flexibly hospital spaces can be re-designed and re-allocated to quickly set up temporary infrastructure like isolation wards, beds and even ICUs. A judicious use of all available space is important in such emergencies. Moreover, hospital staff should be trained for smooth reassignment of responsibilities in situations when the demand is excessively high.
Making digital health technologies a channel for delivering primary healthcare
The Covid-19 pandemic is transforming the global health community’s acceptance and use of digital health technologies. Covid-9 has forced many countries to social distancing to preventing the spread of the epidemic. Building more robust telemedicine systems in hospitals worldwide is may be very important. Firstly, this can reduce the pressure on the hospital infrastructure and resources such as beds, healthcare workers etc. Secondly, those who are healthy can stay at home by not physically visiting a doctor unnecessarily. Thirdly, people who are ill but can be treated online by qualified physicians without the need for special medical equipment can receive prompt and cost-effective care. The current dilemma facing health care systems worldwide is how to sustain the capacity to provide service not only for those afflicted with Covid-19 but also for trauma patients and those suffering from other acute and chronic diseases while protecting the physicians, nurses, and other allied health personnel. It is no surprise that health systems globally are now resorting to telemedicine to provide care while keeping patients in their homes. The massive conversion to telemedicine demonstrates its utility as an effective tool for the so called social distancing in clinical or other settings.
Protecting healthcare workers
The most outrageous failure of many health systems has been, and continues to be, the inability to adequately protect professionals and healthcare workers. Many thousands of health care workers have been infected amid the ongoing coronavirus outbreak, a sign of the immensely difficult working conditions for doctors, nurses, and health care workers in general. They should be instead among those best protected. The infections, along with the deaths of many healthcare workers around the world, have underscored the deeply challenging, chaotic environment that healthcare workers faced with when toiling on the front lines of an epidemic outbreak. They have faced long hours, changing protocols, potential medical supply shortages, and risks to their own personal health and that of their loved ones. In every mass casualty event, the healthcare workers who go to the forefront are the main actors. The lack of action plans forced healthcare workers to work in a situation of extreme unsafety.
If health systems incorporate even some of these ideas in their practice, health systems around the world will be better prepared for the future, however unpredictable it may be.