Health systems around the world are straining under the impact of Covid-19. As the pandemic progresses it is evident that there is much for health systems across the world to learn from each other from these shared experiences, and that when a global pandemic hits the differences between high, middle and low-income countries are increasingly invalid.
This blog brings together the contributions from members of Health Systems Global – an international network of health policy and systems policymakers, practitioners, researchers and advocates – and highlights several common threads from different countries’ experiences and learning.
Swift and decisive action
A number of the countries that responded quickly and rigorously to the emergence of the virus from China’s Hubei province have been highlighted and praised by experts, international agencies and media commentators. In the case of South Korea, its government’s response comprised a number elements, which, with the exception of a surge in reported cases in mid-February, has largely been effective at ‘flattening the curve’ – slowing and then controlling the spread of Covid-19.
The Government’s emphasis on early and extensive testing and contact tracing – instead of the kinds of restrictive measures applied elsewhere – have been a widely publicised centerpiece of South Korea’s response. Regular and transparent communication from national and regional government to the South Korean population helped secure civic trust in government and significant voluntary compliance with social distancing, mask-wearing and hand washing.
Importantly, South Korea’s response has been built on (a) the foundation of a health system with universal health coverage and a national health insurance service that exempts communicable diseases from co-payment, offers free testing, and minimises the financial burden of treatment on patients; and (b) lessons learned from the country’s painful experience of Middle East Respiratory Syndrome (MERS) Coronavirus in 2015.
(Re)building trust between governments and societies
Brazil’s experience also demonstrates how it can benefit from the strengths of its health and social protection systems. This includes the depth and breadth of the country’s community-based primary care network, the national coverage of cash transfer schemes, and the institutional arrangements that have enabled state, civil society and private sector actors to coordinate responses to epidemics that avoid worsening existing health inequities.
However, in contrast to South Korea, these strengths have been undermined by prolonged austerity measures and intense political polarisation that has undermined trust in government and damaged its ability to coordinate its response effectively. Of course, this is not a phenomenon unique to Brazil: high levels of mistrust of public institutions, built over decades of structural inequality and negative experiences, have also been a critical aspect of why African-Americans have been disproportionally affected by the pandemic.
The vital role of community health systems
The Brazilian story also highlights how an overemphasis on acute hospital treatment and care and the neglect of primary health systems is detrimental to response and recovery. This is a familiar tale from health systems elsewhere and reflects a failure to recognise how community health systems can contribute to (re)building trust of the state and conducting core surveillance and contact management for containment, as well as providing basic case management capacity and connecting to other parts of the health system.
In densely populated urban areas, including informal settlements, community health workers, with sufficient support, resources and contextual cultural knowledge, can provide social support to those in self-isolation and help to control the spread of infection in contexts where it is more difficult to control.
System-wide challenges and responses
And yet, the exhausted images of health professionals on social media, give highly visual credence to the stress Covid-19 is placing on the physical and mental health and wellbeing of those on the frontline and exacerbates long-term systemic issues affecting health workforces, from inadequate training to poor working conditions that can lead to absenteeism at the worst possible time. Initial studies from China indicate that Covid-19 has taken a severe toll on the mental health of the frontline health workforce, with particular groups being at higher risk. Attention and worries are now increasingly turning to low-and-middle-income countries (LMICs), including much of sub-Saharan Africa.
Taking a whole systems approach to the response by ensuring that social protection systems, such as cash transfers and public infrastructures for social services, are in place to prevent households and communities from becoming severely affected in the immediate and longer-term is vital, as is engaging private formal and informal providers that account for a large proportion of the health and other social services accessed by poor and vulnerable people in many countries.
In Uganda, private sector drug stores and clinics are the first point of contact for up to 80 percent of people who fall unwell, including around two thirds of children with fever and 12 percent of children with acute respiratory infection. Such providers are on the frontline of the response to Covid-19 but need sufficient resources to ensure that they are well-trained and supported to scale-up their involvement and help contain the virus.
Fake news and knowledge gaps
Coverage of the spread and impact of Covid-19 is perhaps inevitably a 24 hour-a-day global news event. Sensationalist media coverage is combined with more subtle but also damaging misrepresentations in science reports and articles. Incorrect assumptions are being published as facts to fuel the apparent demand for more information.
Whilst we are being hit by this difficult to navigate information and opinion, insufficient evidence (with a significant gap around the impact of non-medical interventions for epidemic control and freely available public modelling tools) means that those advising national governments in some countries, may lack the knowledge they need to design, implement and monitor effective response and recovery strategies.
These insights from HSG members all highlight the common challenges and learnings across different contexts and thus the value of global collaboration and mutual learning between countries, governments and societies around the world, particularly through these challenging times.
