In the 21st century alone, outbreaks of infectious disease have cost untold lives, inflicted severe damage on already inadequate health systems and infrastructures, and triggered economic, social, and humanitarian crises on a global scale. This is despite the fact that with adequate resources, our modern-day capacity for care is such that most people with severe infections can be treated and survive—as Fowler and Rubinson both remarked—and healers should not become ill as is so common in low- and middle-income countries (LMICs) during infectious disease outbreaks. This chapter discusses the crucial, moral imperative to take immediate, practical action in implementing solutions to imbue health systems with the strength, resilience, and sustainability to successfully manage, quell, and endure such emergencies.
Various participants highlighted several crosscutting principles that have the potential to meaningfully impact the success of solutions and strategies implemented going forward. Myers of The Rockefeller Foundation summarized principles as applicable to efforts across the board to strengthen health systems and emergency response capacities:
- Strengthen countries’ everyday health systems
- Build on existing infrastructures, systems, and capacities
- Capitalize on interoutbreak periods
- Communicate effectively and equitably
- Engage multiple sectors
Integrating International Goals and Capacities
With various global challenges and international agendas occurring, there is a concern that the bandwidth of countries might be stretched too thin, or that some goals or capacities could be diluted in the face of so many. While the core competencies of the International Health Regulations (IHR) were the main focus of this meeting, the new 2015 Sustainable Development Goals (SDGs) have areas of crossover, as well as the new Sendai Framework for Disaster Risk Reduction 2015-2030. Omaswa of the African Centre for Global Health and Social Transformation (ACHEST) acutely pointed out the importance of identifying and highlighting the overlap and intersection of related areas so that players at the country level can synergize to achieve progress instead of worrying about an endless list of goals. While not all in each of the lists may explicitly reference health, López-Acuña commented that an effort is needed to integrate the message of resilient health systems, universal health coverage, SDGs, and even unmet Millennium Development Goals to be able to communicate a single, holistic package to policy makers and ministers of health and finance. In order to do this well, as Myers noted, capitalizing on crosscutting principles such as engaging multiple sectors and building upon existing infrastructures would be tremendous first steps.
Multiple participants emphasized the importance of bolstering countries’ everyday, primary health systems (including essential public health capacities) to strive for universal care delivery. While disease outbreaks and corresponding donor funding often draw focus to the surge capacity needs directly related to that specific disease outbreak, having diverse elements of public health embedded throughout a system during and between outbreaks can often be more effective than simply focusing only on surge elements in times of crisis. Strong day-to-day health systems also have the resilience and flexibility to respond quickly and effectively in situations of disease outbreak or other health emergencies, without compromising their abilities to continue delivering essential primary care and other functions not directly related to the emergency. A key topic of discussion among many participants in the workshop was the need to assist countries in building the core heath capacities that form the foundation of an everyday system that is both resilient and sustainable enough to respond to emergencies.
As described throughout this summary, a resilient health system capable of delivering quality care to its population will need basic infrastructure on which to build—including clean water and sanitation for hospitals and facilities as well as well-designed supply chains where laboratory samples
and supplies can be moved throughout a country, discussed by Rasanathan and Matowe. As Panjabi of Last Mile Health presented, including immunizations and maternal and child health services can be a key part of a primary care platform, and can also be achieved through frontline community health workers. Having these and other workers trained not only in their own disciplines for routine care delivery, but also in basic infection control and prevention practices could also assist in halting outbreaks before they progress too far—as Perl demonstrated with the Middle East respiratory syndrome experience in Saudi Arabia. While building all of these capabilities will not happen overnight, several participants saw ongoing investment in sustainable financing mechanisms as a possible way to achieve that goal. Dovlo of the World Health Organization’s Regional Office for Africa (WHO-AFRO) commented that their regional office has been prioritizing the development of coherent and comprehensive national policies encompassing all of these elements for countries. As they get partners to buy in and can complete more analyses, they can work toward a broader approach to universal health coverage, but it will be over the long term. As Anywangwe pointed out, ensuring country autonomy in decision making regarding donor funds will also be essential in ensuring a country’s goals are reached and not just the donor’s goals. See Box 6-1 for a more detailed list of strong health system components.
As Rasanathan of the United Nations Children’s Fund stated in Chapter 1, resilience is not useful for its own sake; rather, it is useful because it allows for more effective health care delivery to patients, and it makes the system flexible enough to respond to unexpected health threats. Resilience and sustainability go hand in hand, Myers of Rockefeller explained, and health systems strive for this sustainable capability because that can allow them to function at a high level for everyday needs, as well as address emergencies and events that strain the system. However, as many participants pointed out, while this discussion is logical in an academic sense, it is not a realistic scenario for many health care systems in LMICs. Not having basic equipment such as gloves and other personal protective equipment (PPE), like they lacked at Marie Claire T checola’s hospital in Guinea, or not having access to clean water as Saran Kaba Jones discussed, can make it extremely difficult to surge capabilities in an emergency. Existing capabilities can be adapted or surged in an emergency, but only if they are adequately funded, operational, and tested in the interepidemic periods. Campbell of WHO summarized the importance of first building a country’s basic health capacities, followed by basic public health capacity, and then looking to increase resilient capabilities for outbreak management and
emergency response—but the order cannot be altered for the system to function in a sustainable manner.
International Health Regulations Compliance
While having countries achieve the core competencies outlined within IHR would be a progressive step toward realizing stronger global health security, it will require continued dedication, said López-Acuña. One of his 10 elements to build resilient and sustainable health systems was to meet
the core commitments of IHR. He suggested that IHR compliance be more prominently mainstreamed into health systems development frameworks and that currently, Official Development Aid has not sufficiently supported this stream of work. He also called for matching up already existing systems where possible. As an example, any emergency preparedness and response system that is created should be dovetailed with the national structures responsible for IHR (such as the national focal points so strong communication is ensured).
Related to this suggestion and perhaps inherently included were two other elements: Discharge the essential public health functions (EPHFs) and strengthen public health infrastructure. The EPHFs can be helpful in understanding the conditions in each country, and standard performance measures and tools that can be built on and adapted are already in place in some areas. For instance, López-Acuña said, in the Region of the Americas, Pan American Health Organization/WHO and the U.S. Centers for Disease Control and Prevention developed performance standards and indicators for 11 EPHFs that they have used to assess and measure EPHFs in all countries and territories of the Western Hemisphere. However, as stated earlier and throughout this summary, many functions within a health systems are interrelated. López-Acuña noted that the strength of the underlying public health infrastructure will dictate a system’s ability to effectively execute the EPHFs. Dedicating resources to a strong infrastructure, especially during the interepidemic period will help to organize the delivery of services during emergencies, he said.
Lessons Learned from Other Countries
Similar to the previous example of performance standards in the Americas, many promising examples were highlighted in this workshop that countries looking to build their health systems could adapt and implement in their own national context. Tomori and Dovlo called for resource sharing regionally and through international support by countries who could not realistically build their own capacity, and would want to avoid duplication when resources are limited. As many have called attention to the lack of resources in many of these countries with fragile health systems, creating redundant systems and capacities in a region would not be efficient. Instead, noted Leung, harmonization should be a goal of international and regional bodies related to response and training needs for specific skillsets related to emergency response.
Integrating donor compliance into country-specific planning was another positive example of creating opportunities for countries to create more sustainable systems. Guhathakurta and Fitter commented on the potential dangers of not enabling long-term and flexible funding mecha-
nisms for countries, creating accidental dependencies and making it difficult to self-regulate at the national level and maintain accountability to all stakeholders, not just donors but citizens as well.
Norton from Australia also suggested the benefits of “twinning” which he noted is a process by which doctors in two or more countries train in each other’s country to better prepare for foreign deployment. This method allows foreign doctors to more clearly understand the uniqueness and specifics of a country’s health system and available resources before being thrown into the environment during a crisis. Rubinson of the University of Maryland added that these deployments would be of even more benefit when done in a team-based environment. Having the advantages of coordinated command and control and logistical independence can facilitate standardized functional capabilities for each team member, and again should allow them to be more productive when entering a high-stress environment.
Lamptey summarized many of these examples, saying that while this effort in building resilient and sustainable health systems needs to be country-led and country-owned, we cannot forget about the lessons that have been learned already. He referenced Uganda’s Ebola experience, Nigeria’s CDC, polio eradication efforts, and the response to the HIV epidemic, and commented that pulling the relevant lessons from these case studies and using those as examples for countries to adopt in a full sector-wide response would be a great step in the right direction. Finally, he and López-Acuña synergized their call for accountability to stakeholders. Lamptey explained that in too many instances, recommendations are geared toward the donor community and other members, but in reality these efforts must be led by the countries with governments taking ownership and responsibility. One participant added that the populations of the country in need of problem solving need to be present and have their voices heard when developing solutions, otherwise, who will truly benefit? López-Acuña agreed, saying community engagement in monitoring and evaluation of health system performance is critical. He called for developing more independent accountability and engagement with civil society and academia. In closing, Omaswa of ACHEST cautioned that though ensuring accountability of donors and governments is warranted and needed, without continued drive, interest, and pressure from the people within each country—the health care workers, the patients, the scientists—things may not change. This continued dialogue and invested interest by all sectors needs to continue to truly solve the problems of fragile health systems.