Introduction.
A health system's purpose is to protect and improve the health and wellbeing of its community. Its services range from promotion, prevention, protection, screening, diagnostic, treatment, rehabilitation, and palliative care. These services are provided across a continuum of self-care, home care, community care, primary care, and hospital settings. While healthcare services are important a community’s health and wellbeing is dependent on broader determinants. This principle should never be forgotten even in a pandemic.
In the event of a pandemic, governments all over the world look to their health system to take a lead role in their response.
In a recent interview, the above question was posed to me. I took a report card approach in my assessment and looked at the three phases in managing the COVID 19 pandemic: a. Preparation b. Response c. Recovery
The answers can differ depending on whether we take a narrow health perspective or a much broader wellbeing perspective.
For now, global citizens are still living in the response phase of the COVID 19 pandemic. How long it lasts remains an open question. The recovery phase of a post-COVID 19 society is yet to start in earnest. What will that look like, and how different will it be compared to the pre-COVID 19 is on everyone's mind. What is clear at this stage is that significant change is around the corner.
Governments are tentatively opening up their country and closely monitoring for any resurgence in infections. There are palpable tension and debate in most countries on the pace and scale of this reopening process.
Amongst the strenuous tasks in the rebuilding countries' economy, governments will be making significant investments in their health system. An important question that needs answers as part of the preparation is, "how well have health systems met the challenge of COVID 19?”
It is essential to start by acknowledging the dedication and selfless sacrifice made by health professionals globally. This assessment is about how health systems perform. It does not reflect on the commitment and selfless contribution made by health professionals and other front-liners in the fight against COVID 19.
Preparation.
In terms of preparation, no matter how we look at this phase, the report card score has to be a "fail." There 2 were plenty of warnings leading up to COVID 19. There were SARs (2003), Swine flu (2009), MERs (2012), Ebola (2014), and Zika (2015). By and large, governments and health systems around the world ignored the need to be better prepared for the "big" global pandemic. With minor exceptions, most countries did not take the warnings seriously to invest in the basics, such as adequate stockpile of personal protection equipment (PPEs), prophylactic medicine, vaccine development, diagnostic testing, contact tracing, and hospital capacity.
A few countries did make the preparations (South Korea, Taiwan, Singapore, and Hong Kong), and it mostly put them in a better position to respond to this pandemic. Even so, the latest developments in Singapore and South Korea demonstrate the challenge of responding to this pandemic's dynamic nature.
Response.
In terms of the report card for the response, phase, there are three parts. The first is protecting people from COVID 19, the second is protecting people’s overall health, and the third is protecting people’s wellbeing.
1st response report card (protecting people from COVID 19)
Protecting people from COVID 19, the report card is a mixed bag at this stage of the response. This phase will not be over until an effective vaccine becomes available globally— a realistic timeframe for an effective vaccine to be available globally in late 2021 or early 2022.
Examples (at this stage of the pandemic) of countries that managed it well includes Australia, New Zealand, Germany, Iceland, South Korea, Hong Kong, Taiwan, Vietnam, and Singapore. However, as counties reopen, infections are resurfacing, resulting in the reintroduction of lockdown measures.
Tragically, there are glaring examples of government failing to protect citizens, especially the elderly and other vulnerable communities. From a mortality indicator USA, UK, Italy, Spain, Belgium stands out for now. Unfortunately, a similar trend is emerging in Brazil as COVID 19 starts to shift its deadly impact to South and Central Americas, the Indian sub-continent and Africa. These countries have a less robust health system, more impoverished and less resilient communities, and crowded living conditions provide fertile grounds for potential widespread infections and fatalities.
Another significant black mark on the current COVID 19 response has been the "one size fits all" approach by governments to combat this pandemic. The suppression strategy is the widely accepted response (unless you are in Sweden) with its broad lockdown and social distancing measures.
It does not require a rocket scientist to work out that this was not going to work in many developing countries. Communities in poverty cannot be effectively lockdown for months. Social distancing is an illusion for their dense living conditions, and personal hygiene is impossible without easy and affordable access to clean water and soap. An outlier amongst developing countries is Vietnam. Its government's strong and early decisive actions, a younger population, and a culture of social obedience to government directives contributed to a relatively low number of infections and even fewer deaths.
Hence, the report card for the first part of the response phase is mixed.
2nd response report card (protecting people overall health)
Most developed countries suspended all nonCOVID 19 health services to ensure hospitals could cope with COVID 19 patients. In some countries like Italy, Spain, and the USA, their hospitals were overwhelmed with COVID 19 patients. Deferring all other non-COVID 19 was the right decision. In many developed countries, some of these non-COVID 19 health services are slowly coming back into service.
However, questions on the long-term effect for patients with cancer, heart disease, and mental health conditions that had their treatments deferred by months or possibly years are now surfacing. There will be health and wellbeing consequences with these delays.
The infographics below provide a daily snapshot of COVID 19 death against other leading causes of mortality.
In the next few years, it will be necessary to monitor whether there is an unusual increase in overall mortality numbers and whether delays have caused it during the response phase of this pandemic.
On balance, when it comes to protecting people’s overall health, no countries health system gets a pass mark.
3rd response report card (protecting people overall wellbeing)
The Imperial College of London COVID 19 Response Team report dated 16 March 2020, is a seminal document in this pandemic response. This report's modeling forecast unimaginable deaths if governments hesitated to adopt its recommended suppression strategy. It triggered many governments to put in place suppression strategy lockdown and social distancing measures in the third week of March. This report's authors clarify they have not considered the ethical or economic implications of either strategy here, except to note that there is no easy policy decision to be made. Suppression, while successful to date in China and South Korea, carries with it enormous social and economic costs which may themselves have a significant impact on health and wellbeing in the short and longer-term."
It is not clear whether governments receive other advice and modeling on the broader social, economic costs before adopting the recommended suppression strategy.
Governments gave minimal warning to anyone and had no strategy of how it would reopen the country. Overnight, with borders closed, and people confined to their homes, many countries' economies virtually collapsed overnight. Developed countries' governments scrambled to put in place significant life support fiscal packages. These were designed to soften and delay the impact of inevitable unprecedented large-scale business collapse and rise in unemployment.
The intensity and depth of hardship to the average person and families will start when government life support handouts stop as countries face the inevitable global deep recession or depression.
For developing countries pursuing the suppression strategy lockdown and social distancing measures, the social and economic fall-out is exponentially worse. These countries have weaker health infrastructure, less resilient economy, an already debt-laden government balance sheet, large densely populated communities, and millions of its citizens surviving from hand to mouth. They also have poor access to regular clean water and soap necessary for good personal hygiene.
For these developing countries adopting a suppression strategy's lockdown and social distancing have put millions of people out of work and unable to feed their families. According to Imran Khan, the Prime Minister of Pakistan, his country’s suppression strategy has resulted in 25 million people without work affecting 25 million families and at least 120 to 150 million people (57% to 71% of the total population). That is why he has no choice but to reopen the country; even the infections and deaths are not where it should be.
When it comes to protecting people’s overall wellbeing, no countries health system gets a pass mark.
Recovery.
In terms of recovery, it is far too early to score yet. Some governments are starting to turn their attention to rebuild their health system as part of their recovery phase in this pandemic. Three pillars will decide the success or failure of health systems recovery. The first pillar is the principles that anchor any health system reforms.
These principles include:
- Wellbeing rather than just health.
- Aligning health systems as solution partners to other global challenges like climate change and food security.
- Equitable access to affordable, timely, high quality and culturally appropriate services.
- Prevention, self-care, community and primary care rather than just hospital based treatment.
- Diversity in contribution and approaches.
- Consumer experience, choice and control.
- Privacy, security and trust.
These principles need to underpin the redesign content and process of post-COVID 19 health systems. Adherence to these principles will require post-COVID 19 health systems to address many of the unresolved issues of existing health systems.
The second pillar is the implementation approach and transformation features of post-COVID 19 health systems.
These include:
- Embracing 4.0 technologies and the use of data
- Health services and supporting operating model
- Dual transformation approach to reforms
- Developing resilience and agility to pivot, scale and respond
The overnight adoption of digital platform virtual care during COVID 19, and the proliferation of contact tracing applications, provides a small glimpse into 4.0 technologies that can make revolutionized health systems. Insights from the sharing of multiple sources of data have played a crucial role in fighting this pandemic. From the sharing of the genomic profile of the virus, tracing and tracking suspect cases and close contacts have demonstrated the value of having timely access to relevant data.
An operating model supports all existing health services. Any change to existing health services needs to accompanied by changes to the supporting operating models. Likewise, new health services introduced will need to be accompanied by an appropriate operating model.
Dual transformation requires the health system to pursue a dual agenda of reforms. The first agenda focuses on improving existing health services and delivery models. The second agenda focuses on implementing new health services and delivery models with 4.0 technologies playing a key role.
Health systems post-COVID 19 need to develop greater resilience and ability to pivot, scale, and respond to the dynamic nature of multiple complex challenges. Future health systems, for example, cannot afford to defer other health services when responding to a single existential threat.
The third pillar of the right talent, capacity, and capability is probably the health system's greatest challenge. Such talent, capacity, and capability are developed deliberately. There is little doubt that without the infusion of new talents alongside a careful selection from existing health system leaders, the health system post-COVID 19 runs the risks of looking remarkably like the pre-COVID 19 version.
Many previous health reforms have failed because health systems traditionally have not welcomed talents from other industries. There is far too much recycling of existing health leaders. Leaders need to have the capacity and capability to stop, modify, deliver existing services more efficiently and effectively, and learn, innovate, and respond to new knowledge, technology, and other societal and environmental changes.
Final word.
COVID 19 has caught governments around the world completely off-guard. In the interest of preventing health systems from being overwhelmed, governments implemented sudden and drastic lockdown and social distancing measures. Many were too slow to act, and the staggering statistics of infections and deaths bear witness to their delayed actions. Even for governments who acted early, the adverse consequences on the broader social and economic determinants on people’s wellbeing is clear and will be felt long after this pandemic comes under control.
Post-COVID 19 health system needs to learn from its failure in planning and blunt response for this pandemic. Future responses to the next pandemic should not cause the deferral of other health services, avoid triggering another deep recession or depression, and send hundreds of millions of people in developing countries into poverty.
Finally, the post-COVID 19 health systems need to address long-standing issues such as equity and disparities, embracing technologies 4.0, and be solution partners for other global challenges such as climate change, poverty, and food security.
The report card on planning is a definite “fail” and for response reads "mixed with the potential to get worse”. Needs fundamental change and improvements." How well health systems recover post-COVID 19 will fundamentally come back to the quality of leadership talent, capacity, and capability. For now, the report card for the recovery phase reads, "early work in progress with a difficult and long road ahead".
Chai Chuah - 1 June 2020