3 priorities for stronger and more inclusive health systems

Nearly two years into the COVID-19 pandemic, progress towards achieving universal health coverage (UHC), has stalled or gone backwards, disproportionately affecting those most left behind. Progress must be accelerated to improve health security and resilience to crisis, and to ensure everyone has access to high-quality healthcare. We call for progress on three priority areas: primary health care, sustainable financing and strengthening the health workforce.

COVID-19 has highlighted the consequences of years of under-investment in health systems. The 2021 UHC Monitoring Report by the World Health Organization (WHO) and the World Bank highlights slow progress in improving coverage and continuous challenges for health systems to provide financial protection. Emerging lessons from the pandemic indicate disrupted access to non-COVID essential services, more vulnerability towards impoverishing impact of out-of-pocket expenditures on healthcare, and widening inequities.

WHO has released a position paper on building health systems resilience towards UHC and health security during COVID-19 and beyond. The OECD has, since the 2008 financial crisis, helped governments look at resilience as a multi-system challenge requiring policies to prepare for and recover from high consequence shocks. The World Bank is working on operationalizing the resilience concept for support and investment. UHC2030, the shared multi-stakeholder platform for UHC, which our organizations co-host, is mobilizing advocacy and action on health systems for UHC and health security.

As we have reiterated in our previous work, Primary Health Care (PHC) is the engine for UHC. The 2021 World Bank report Reimaging PHC after COVID-19 shows how in crises and at ordinary times, strong PHC saves lives and money and makes health systems work better for all people. In health emergencies, PHC plays an important role in surveillance, testing and contact tracing, and in keeping hospitals from overflowing with critically ill patients. The 2019 OECD report Realising the Potential of PHC, showed that strong PHC systems are key to the efficient delivery of crucial health services, including vaccinations.

Overlooking the central role of primary care slowed the effectiveness of the response to the pandemic and triggered disruption to routine care in many countries threatening progress made over the past years. On average, countries reported half of essential service having been disrupted in 2020 and still a third in early 2021. Front-line services remain weak yet less than one in six dollars is spent on primary healthcare even in high-income countries.

Leveraging developments in digital innovations to maintain services and improve surveillance offer new opportunities, PHC systems need to reach new performance levels in four strategic shifts:

1. From low-quality PHC services to high-quality care for all

2. From health service fragmentation to person-centred integration

3. From inequity to fairness and accountability

4. From fragility to resilience.

The 2021 UHC monitoring report shows that even before COVID-19, the world was off-track to reduce financial hardship caused from paying for healthcare out of pocket. A recent World Bank paper on health financing concluded that many developing countries will not recover to pre-pandemic economic levels before 2026, putting at risk health financing at the time when countries still have to respond to the pandemic, invest into preparedness and ensure access to essential health services without financial hardship. This calls for continued and targeted external support to countries most in need. The OECD has calculated that even in high-income countries, an annual investment of 1.5% of GDP is needed to make health systems resilient enough for another major health threat of the scale of COVID-19.

Increasing health taxes on tobacco, alcohol and sugar-sweetened beverages offers opportunities to improve health in the medium to long term, while in the short term increasing government revenue and thus fiscal space for essential expenditures.

Further reforms are needed. COVID-19 calls for accelerating public financial management (PFM) reforms. Countries with more flexible and accountable financial systems were better able to allocate and track funding for the response. The recent Montreux Collaborative meeting in November 2021, held by WHO with key partners, offered great insights on possible ways forward to accelerate PFM change.

COVID-19 has shown the urgent need for more health workers. WHO has estimated the global health workers shortage at 18 million before the pandemic, in particular in Africa and South-East Asia. During the pandemic, 66% of countries reported insufficient staffing as the reason for service disruptions. Even in high-income countries, the lack of health and long-term care staff has proved to be more of a binding constraint than hospital beds and equipment.

Between 40% and two-thirds of surveyed health workers in a number of countries reported mental health problems during the pandemic (OECD Health at a Glance). WHO estimated around 115,000 deaths among health and care workers between January 2020 and May 2021.

While there are no quick fixes, changes are needed to training, deployment, management, evaluation and compensation of healthcare workers. Medical education should be revamped to focus on collaborative and integrated team-based care, including in PHC. Digital technologies can help with decision support, team work, task shifting and patient participation.

As the clock ticks down to 2030, and with no end to the pandemic in sight, we must all remain united in strengthening health systems to respond to emergencies effectively and progress towards UHC, leaving no one behind.