Better health systems as a vaccine against the next Pandemic

This first blog of 2021 focuses of the need to transform healthcare delivery globally.  We are delighted to hear from Dr Philip Mathew, an Associate Professor of Community Medicine and a public health consultant based in India. Dr Mathew is also a doctoral researcher in Global Public Health at Karolinska Institutet, Sweden.

The Covid19 pandemic has ravaged the health systems of countries- both rich and poor. We saw shortages of basic personal protection equipment in healthcare facilities of Europe and people reusing surgical masks in the United States. We saw oxygen running out in Uganda and people dying of lack of ventilation facilities in Brazil. Covid19 laid bare a global healthcare delivery system, which was underprepared, underfunded and frankly broken in many places. At a time when we see light at the end of the tunnel in the form of an effective vaccine, it’s time to think about the kind of health systems we want for our future.

In most Low-Middle Income Countries (LMICs), the healthcare spending as percentage of Gross Domestic Product (GDP) has consistently been low due to various reasons. As per World Bank data, South Asian countries spend 3.46% of their GDP on health and sub-Saharan countries 5.12%. At the same time, the countries in the Eurozone spends 10.14% and North American nations spends 16.55% of their GDP on health. This is happening despite the much higher burden of disease, as measured using Disability-Adjusted Life Years (DALYs) per 100,000 population, in the LMICs. The ‘Abuja declaration’ which was adopted by the African Union countries in 2001 called the countries to spend at least 15% of the national budgets on health. But almost 20 years on, very few countries have managed to achieve the modest target. One of the reasons for this apathy is the need for health to compete with more visible issues like water, sanitation and poverty. Though the competing sectors are all health-sensitive, it cannot substitute direct investment in health. Another perceived reason is that healthcare never features in the election narrative in most LMICs. Access to health is not debated in the way graft, poverty or war is discussed during a national election. The end result is that the politicians do not feel compelled to recognize or act on the chronic shortage of funds for the healthcare sector. After witnessing the economic disruptions of a Pandemic, we can hope that health is prioritized while taking decisions regarding national budgets in developing countries.

Universal Health Coverage is another significant facet of the healthcare system we want for the future. It is based on the principle that every human being, despite physical, economic or identity differences, should have equitable access to healthcare. A Universal Health Coverage (UHC) system should be able to deliver the full spectrum of quality assured and essential healthcare services, to the entire population of a country. The importance of UHC in the future of this world was reaffirmed at the High-Level meeting convened by the United Nations General Assembly (UNGA) in 2019. The outcome was a political declaration which stressed on the need to achieve UHC by 2030 and the importance of health in the 2030 Agenda for Sustainable Development. Many commentators are of the opinion that the highlight of the political declaration was the acceptance that primary healthcare is the cornerstone for building a robust health system for UHC. A people-centred healthcare delivery narrative based on strengthened primary care services may be the right route to achieve UHC in all LMIC contexts. The public perception on healthcare is often driven by the image of large hospitals and well-adorned doctors. But health of communities are often determined by the quality of primary care services and the competence of health extension workers. This fact is often hidden and the end result is that valuable resources are spend only on augmenting tertiary healthcare, while primary care sector is left wanting. This has to change for good in the post-Pandemic era. We saw the importance of primary care in contact tracing, quarantining, isolation and ambulatory care of Covid19 patients. This system should be strengthened and it should form the pedestal on which UHC should be built.

One of the defining problems of the Pandemic was gross failure of supply chains for critical healthcare delivery equipment and essentials. The shortage of masks in the emergency departments of hospitals in the United States was because of their dependence on other countries and not some lack in purchasing power. The manufacturing processes and production of Active Pharmaceutical Ingredients (APIs) for drugs are concentrated in a handful of nations; and disruptions can leave the rest of the world vulnerable to shortages. During the peak of the first wave of Covid19, big pharmaceutical producers like India banned the export of critical drugs like Paracetamol and Hydroxychloroquine. This shows the need for decentralizing the manufacturing processes for essential medical care equipment, consumables and medicines. The concentration of manufacturing was primarily due to cost efficiencies and this can be easily overcome by providing push incentives for manufactures. Now the European Commission is in the process of formulating a holistic pharmaceutical strategy which covers the whole life cycle of drugs, including shifting API production closer to home. Apart from this, the United Nations Conference on Trade and Development (UNCTAD) has been working to put in place strategies to augment pharmaceutical production capacity in African countries. All of these efforts should be fast-tracked in view of the Covid19 outbreak and the increased potential for global supply chain disruptions in the future. Humanitarian agencies like Unitaid has expertise in supply chains and that can be used very effectively for strengthening the healthcare system of countries. A twin strategy of localising production and strengthening supply chains is the only way forward to hedge against potential large scale disruptions in the future.

Traditional thinking and narratives have dominated the public health systems of most LMICs and this sector has been slow to adopt technology to improve efficiency of healthcare delivery to large populations. There is reasonable quality evidence to show that Artificial Intelligence (AI) based m-health tools can reduce the need for human resources in healthcare delivery. The critical gaps in healthcare human resources that poorer countries face, can be overcome by use of such tools. Some pioneering companies have demonstrated that such AI tools coupled with micro insurance can solve a significant proportion of healthcare needs of economically disadvantaged sections of the society in LMIC contexts. But the uptake of these technological innovations has been very slow in most health systems, mostly owing to the way in which public health is taught and practiced. The building blocks of the healthcare system of twenty-first century should not be limited to just people, medicines and buildings, it should integrate technology at each level to improve efficiency and coverage.

Lastly, improving the resilience of healthcare systems also involve optimizing the market for healthcare products. When the world was scrambling to come up with an effective Covid19 vaccine, hardly anyone noticed that Tuberculosis kills almost a similar number of people and we only have a century old vaccine with very doubtful effectiveness profile. We still do not have an effective vaccine for Malaria, which kills almost half a million people every year. The world is looking at a post-antibiotic era, as most of the antibiotics have been made redundant due to Antimicrobial Resistance (AMR) and an empty antibiotic Research and Development (R&D) pipeline.  There has been a ‘market failure’ for vaccines and antibiotics, frankly because the larger pharmaceutical companies did not see an opportunity for profiteering. There was a perception that these infections were present in ‘faraway, poor, tropical’ countries, which could not afford to pay for the new drugs. So the focus of pharmaceutical R&D shifted to more lucrative areas like cancer and other non-communicable diseases.  This has to change for good, for the health of the world’s population and principles of justice. The pharmaceutical R&D in domains like antibiotics need to incentivised through various push and pull incentives. Besides, when a product is ready for the market, it has to be accessible to the groups who need it the most. Therefore, the cost of pharmaceutical R&D has to be delinked from the price paid by the end user. These are very lofty principles and there has to be a lot of thought into methods to implement them without affecting the health of the markets.  The politicians who control the purse-strings globally needs to understand that investing in vaccines and antibiotics is like buying a fire insurance for your home- just because your home did not catch fire for 10 years, it does not mean that you can stop buying the insurance. A spark from a short-circuit is enough to burn down an entire lifetime of savings!

Covid19 is indeed a harsh wakeup call for all the health system managers and public health enthusiasts. It showed us that the economic and social disruptions of a Pandemic can be devastating and much more serious that we could ever anticipate. When the environmental pressures are increasing, it is only logical to assume that another micro-organism with Pandemic potential can emerge anytime. With the levels of air-travel that we see, the micro-organism may not take much time to spread across the world. Though it may sound alarmist, preparing ourselves for the worst case scenario may be the only option. For that, we need better health systems and cannot afford status quo!

Photo credit: ReAct Group Europe

Opinions expressed within this article are those of the author and are not necessarily representative of CE4AMR as a network.  If you would like to contribute a blog or opinion piece regarding the inclusion of AMR within the SDGs or Build Back Better dialogue please contact Jess (j.mitchell1@Leeds.ac.uk).