Dr. Shweta Singh and Dr. Shrikant Kalaskar
Epidemiological and demographic transitions have dramatically changed population health needs across the globe. Dynamic health needs are increasing owing to emerging and re-emerging zoonotic infections, environmental degradation, a burgeoning epidemic of socio-behavioral illnesses, health disorders of the elderly, non-communicable diseases, pre-existing communicable conditions, trauma and accidents, and armed conflicts. To serve these emerging health needs of the population, health systems need to be flexible enough to learn from the past and adapt to the changing needs of the people, while maintaining continuity in function. Unfortunately, COVID-19 has shown that health systems across nations, at one point in time or another, have failed to constantly deliver solutions on a large scale. This is because often health systems are short-sighted and crisis-driven. To address these concerns and find sustainable solutions, we need to understand the nuances and complexities of health systems.
Health systems are complex, adaptive systems. The inherent dynamic interaction between its multi-elements, emergent behavior, divergence, non-linearity, and convergence further add to this health system’s complexity. Humans, with limited resources, have designed health systems. Sudden, unpredictable crises shock the health system, affecting its crucial functional continuity across varying conditions and wiping out all the gains made in the past. Therefore, responsiveness and resilience should be integral properties of the health system while demonstrating integration among different disciplines and continents.
“Resilience” is the health system’s property, enabling it to manage severe catastrophes while maintaining continuity. Unfortunately, the past episodes of Ebola, SARS-Cov-1, MERS, and the recent SARS-COV-2 pandemic have exposed the absence of resilience in health systems. “Responsiveness” in the health system implies its ability to anticipate the upcoming situation and cater to the need of people with zero discrimination. A responsive and resilient health system stitches all its essential elements and works in an integrated manner.
What we need to achieve is evident. How to achieve this is context specific to most health systems worldwide as each health system is unique. However, a few common critical preconditions for building a resilient and responsive health system, which should be well thought out globally, are discussed below.
To begin with, a strong commitment from nations, i.e., political will is most important. Health systems globally are too occupied by the target-driven approach rather than focusing on processes, resulting in the fragility of health systems. Moreover, vested interest further deteriorates the condition rather than supporting the system to improve its overall technical capacity. In addition, nations’ commitment to strengthening their primary care and preparing health systems for any shock becomes vital.
Legal frameworks are another vital aspect of the health system to become resilient. In addition, comprehensive, evidence-based guidelines, as well as working in coordination with specialized agencies, are equally crucial. For instance, in Tamil Nadu, the legally endowed Public Health Act has empowered the establishment of a separate governance structure with a dedicated health workforce to carry out public health responsibilities in the state. Moreover, the well-defined policies and legal framework have enhanced its implementation.
In contrast, we have witnessed robust and resourceful health systems being unable to fully meet the health needs of its people. To match the demand and prepare for the shock, it is necessary to predict the impending outbreaks early, contain them locally, and inform the world about them. This is only possible if countries abide by policies like International Health Regulations, global health security agenda, or any other regional data sharing agreement like the Mekong Basin agreement.
Sustained investment, shrinking general funding, and separate funding for vertical health programs from donors have added complexities. This diminishes focus on non-incentivized health programs, irrespective of their impact on the health system as a whole. The selection of cost-effective health intervention is also significant and is evident in countries like Costa Rica and Ethiopia, which have achieved good health at a low cost. Providing reserve funds or pooling funds during crises seems a distant phenomenon, given the struggle for appropriate funding for strengthening health systems in most developing countries, including India.
In the pursuit of equity, a robust health system should be a rights-based model, in contrast to most of the ones today that are entrapped in values of philanthropy and fail in community engagement. Health systems should modify their health service delivery approach and simultaneously empower their citizens in demanding health services. Thailand has outperformed many countries by focusing on primary care elements and providing essential maternal and child health interventions.
Action on the wider determinants of health is necessary. There is a lack of coordination with other sectors such as education, water, sanitation, animal husbandry, nutrition, etc., that are closely correlated with the health of individuals. Despite being well acknowledged in the literature, systems often fail at applying this d adequately in practice. There is a need to emphasize an integrated work approach among different sectors.
Apart from this, increased focus should be put on the role of research in generating evidence for buttressing health systems. Active linkage and exchange between researchers and policymakers encourage evidence-based policymaking and policy-informed research.
People are the principal stakeholders in the health system, and their satisfaction should be at the center of the health system. Lack of contentment brings down community engagement and imperils demand-driven health service delivery.
Capacity building and enhancing ownership should be continuous in the health system across all levels. The role of and the coordination between healthcare providers and the community is enhanced during the crisis. It has several layers, which must be unfolded as resilient performance co-creators. This, in turn, will enable the system and ensure satisfactory delivery of health services, propionate to the emerging pattern of health needs.
Moreover, a health system that can sustain itself in non-emergency times and constantly deliver to the changing population needs is the one that can survive the crisis and will emerge as a champion. The idea is that emergencies and crises cannot be stopped, so our efforts should be to make the health system prepare better and have minimum damage post-crisis. What worked in one country or state may not work in another; therefore, approaches should be contextualized per local needs. Also, it is essential to state here that there is no single definite approach to attain health system resilience and responsiveness; instead, several diverse methods are arising from different disciplines, sectors, and perspectives, which collectively can bring the desired results.
A Systems approach accelerates a more realistic understanding of what works for whom under what circumstances. Of course, adopting a systems approach might involve as many challenges as opportunities. Still, in the long run, it will help build a nation’s capacity to overcome health system challenges by using the evidence from research and informed policymaking. The real knack is to identify challenges and convert them into opportunities to strengthen the health system and be used to enhance local ownership.
It implies explicitly that the gradual shift of focus should be on health systems that are responsive to the population’s needs and, at the same time, are resilient to absorb any health breakdown and maintain continuity. The fact that health outbreaks and emergencies do not identify the national borders and health crises in one nation can reverberate across regions and the world. This indicates that a responsive and resilient health system is for the global public good and welfare. Therefore, a responsive and resilient health system is a prerequisite to sustainable global health development.
Photo Credits: WOSU