Social systems have evolved over time to secure people against enemy, nature’s fury, hunger, and disease. A core function of health systems is to secure people against various health crises arising out of infectious outbreaks, climate change, war & strife, and famine among others. The Covid-19 pandemic has exposed the fragility of health and social systems across the world and their failure to protect people against the loss of lives and livelihoods. What makes systems resilient to such crises? What are the characteristics of a resilient system and how to build them?

Surveillance

Societies have been building surveillance systems since several years now. These systems have evolved over time alongside the evolution of humans and technology. Satellite systems have enormously strengthened the surveillance of borders and have also helped us keep track of climate change.

Disease surveillance remains a core function of public health systems. Over the years, countries, including the developed world, progressively reduced their funding for public health in general and surveillance systems in particular. In India, the Integrated Disease Surveillance Program (IDSP) was established in 2004. It publishes surveillance data on its website on a weekly basis. Despite achieving significant progress since the establishment of IDSP, disease surveillance in India continues to lack robustness. While the public healthcare system provides the required surveillance data, this not seen in the private sector that dominates healthcare provision. Private sector surveillance data continues to remain poor.

More than half of all sanctioned positions for public health professionals remain vacant in India. There is no standardized education system for training public health professionals in the country, unlike those for medical and nursing professionals. There aren’t enough functional public health laboratories that are essential in disease surveillance. Problems facing the information and communication systems developed under the IDSP have persisted over time. With the recent attempts at increasing the budgetary allocations for public health, there has been some  focus on strengthening public health laboratories. Successful implementation of the National Digital Health Mission has the potential to improve disease surveillance significantly. Digital technologies, including Artificial Intelligence and big data analytics, provide opportunities for continuous disease surveillance, automated disease alerts and can support rapid response systems.

Redundancy

With globalization, we have been witnessing increasingly efficient systems with just-in-time supply chains scattered all over the world, minimum reorder levels almost touching the bottom, and full capacity utilization. There has been a growing chorus on the need for efficient health systems as the cost of healthcare has been growing faster than the economy in many countries.

Organically evolving systems that face continuous challenges and crises have in-built back-up systems. Societies that face financial hardships have turned to a culture of savings. The tradition of gifting gold at weddings evolved as a means to safeguard families against financial crises. Hospitals in India invest in excess power backup capacity in preparation for crises arising out of erratic power supply. Countries invest heavily on training their armies to defend their borders during the rare event of a war. Though efficiency and redundancy appear counter-intuitive, they can co-exist and be complementary. Risk management is an important component of any management system today. Identification of vulnerable critical points in a system, imagining worst-case scenarios to stress test the system, and putting in place risk mitigation strategies are essential components of good governance of any system. While back-up redundancy is needed in these areas, other areas can be pushed towards efficiency.

Unless we have centralized information on the existing capacity, we will not be in a position to plan for crises. Information should be readily available about every producer of health goods (drugs, devices, disposables, diagnostic equipment and tests, biomedical equipment, life-saving equipment), their production capacity and their stockpiles to plan when in need. There must be records of all providers of health services (doctors, nurses, hospitals, oxygen-beds, ventilator-beds, operation theaters, pharmacies, diagnostic labs etc.,), their location and their capacities to respond to a crisis. National Registers of providers and producers are among the core pillars of the National Digital Health Mission (NDHM). Governments should leverage the information available with them to monitor and plan for present and future crises to make systems more resilient.   

Self-Reliance

The Covid-19 pandemic resulted in supply chain disruptions across multiple sectors globally. As large parts of the world increasingly move away from globalization and towards nationalism, countries, including India, are looking at becoming self-reliant. Countries are increasingly adopting trade sanctions as a proxy in growing geopolitical conflicts. Within India, states are closing their borders restricting the movement of essential goods and people. Self-reliance is not against global and universal outlook. It is a means to remain free and independent, even at an individual level. It should not preclude seeking outside help when needed but should aim at minimizing this need. It should not lead to premature import restrictions when one is not yet ready.

Rapid Response

Biological systems activate multi-level (cellular, organ, spinal, limbic, and frontal cortex) rapid response systems to a threat – real or perceived. Similar systems should be in place to respond to population health threats. Just as armies, disaster response teams, and fire safety departments are in constant state of readiness to mount an effective and efficient rapid response, public health systems should also be battle ready for any signal of threat to people’s health. This involves identification of people and institutions essential for rapid response, their periodic training and assessment, control room led coordination of the response, and debriefing sessions after the crisis is over. Since India has mixed health systems with private health sector dominantly contributing to healthcare provision, it is critical to involve the private system equally in preparedness and response. For the entire health systems to be resilient, private sector engagement should extend to all dimensions of health systems and not to emergencies alone.

Social security

Health system is an integral part of social systems. A variety of social systems (so-called social determinants of health) influence the functioning of health systems in improving the health status of people. People’s health also has an important bearing on other social systems, including the economy. Food and financial security are of prime importance during various crises. People need money to survive and pay for their unforeseen health needs. Various crises lead to increase in unemployment. Coupled with this, there will be likely increase in health expenditures and occasionally the loss of a sole bread earner in the family.

Covid-19 has exposed the inadequacy of existing financial protection systems across the public, social, and private health insurance sectors. Either insurers are denying the authorization for services or providers are denying cashless facility given the disallowances they are facing from private insurers and the uncertainty of receiving claims from public health insurers. The end result has been that people are left to fend for themselves and face catastrophic health expenses. Hence, there is a need to revisit health insurance markets to make them more responsive in crisis situations. Resilient systems plan for robust social security networks to face the ever growing crises.

Learning Networks

Despite planning, people face hardships during various crises. The United States of America was ranked number one in pandemic preparedness. And yet, it failed miserably in its response to the Covid-19 pandemic on many levels. China, Taiwan, New Zealand, Australia, Singapore, South Korea, Thailand, Vietnam etc., handled the pandemic successfully. India seemingly handled the pandemic reasonably well until the second wave hit, demonstrating the fragile state of its health and other social systems. It will be useful to understand why one system failed and the other one succeeded. Pandemics and climate change do not respect borders. Hence, there is a need for collaborative learning networks at global, national, and subnational levels to learn from each other in building resilience in their systems.

One Health

Human beings have dominated the earth, often at the expense of millions of other beings in the ecosystems. The world has evolved over millions of years through a delicate balance between various living and non-living elements. In the name of development, we have been disturbing the delicate ecological balance over the last 100 to 200 years. Advances in technology are only hastening the process. Indiscriminate use of pesticides, chemicals, plastics, and antibiotics are altering the biological milieu in unknown ways.The health of all other biological systems is vital to ensure the health of the human race. Similarly, unless the pandemic is controlled in every part of the world, people will not be safe. This understanding of One Health and respect for every living being is vital to building resilience. The developed world should support the developing world to strengthen their health and other social systems to make the world safe.

Take away message

Health systems must not only be responsive to people’s health needs, but also  be resilient enough to protect them against the increasingly frequent crises. The leadership should have a good understanding of complex social systems to lead and govern them well. If not, they should seek expert guidance from those who understand these complex systems well. Redundancy in critical areas is vital to build resilience and does not negate the need for efficiency. Adequate investment in public health professionals is essential. Standards-based, privacy protected information and communication technology are vital to building robust surveillance systems. Every country should provide an effective social security net to tide over these crises. We have to restore the old saying “SarveJanahSukhinoBhavanthu” (Let all beings be happy) to bring the spirit of One Health. We have to secure people’s health as a collective social responsibility.

Dr Krishna Reddy Nallamalla
President, InOrder
Country Director, ACCESS Health International

*Photo Credits: News Caravan