The panel © GIZ

At a WHS 2022 session on financing and strengthening health systems, global leaders and politicians unanimously agreed on the urgent need to invest in systems for community health, as a fail-safe, high-return investment for stronger health systems and building resilience for future pandemics

At the WHS 2022 opening ceremony held on the previous evening, Germany’s Chancellor Scholz set the scene for many of the conference events when he touched on the need for a more cooperative and multilateral approach to global health security, and highlighted the interconnectedness of health security, biodiversity loss, climate change and poverty. Against the backdrop of Germany’s G7 leadership, State Secretary Jochen Flasbarth of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) was joined by Peter Sands and Seth Berkley, heads of the GF and GAVI respectively, and the WHO’s regional Director for South-East Asia Poonam Khetrapal Singh, to discuss the key role that multilateral actors can play in support of countries and communities to strengthen their health systems. 

They were joined by the Executive Director of WACI Health Rosemary Mburu and Dr Misaki Wayengera, Chairperson of the Scientific Advisory Committee on COVID-19 and the National Task Force in Uganda’s Ministry of Health. Maelle Ba of Speak Up Africa chaired a lively and interesting discussion that touched on a number of key themes related to the strengthening and financing of systems for health as a prerequisite for enhancing prevention, preparedness and resilience for future pandemics, while ensuring that essential health services reach the most vulnerable, leaving no one behind.

Investing in health is the smart thing to do…

Dr Singh was the first of many to point out that investing in health promotes economic growth and stability. There is a strong economic rationale for investing in primary healthcare in particular, through its potential to improve health outcomes, health system efficiencies and health equity. Referring to the climate change community who talk of green growth and green jobs as a good role model, Dr Peter Sands highlighted the fact that we too need to do a far better job of selling health as an engine of growth, rather than a burden on ministries of finance.

The cycle of panic and neglect is unfortunately common to all countries and their societies. Panel members all agreed that underinvestment in health, particularly in preventive health care and preparedness for epidemics, is highly inefficient, leading to higher long-term costs.

Dr Singh neatly summed this up saying:

There can be no economic security without health security. Weak systems in one country pose a threat to others. Let us not forget that the costs of inaction are far greater than the costs of action.

Dr Singh

 …and is also a political decision

Rosemary Mburu of MACI Health reminded everyone that local decisions regarding investment of external funds are both political and highly complex. While a particular investment strategy may be clear to multilateral institutions and donor countries, based on the evidence of what works elsewhere, recipient governments also have to be persuaded that this is the right course of action. This means placing investment decisions within a country’s wider context – their history and political economy. The overall pie is small to begin with, and has to be divided according to a country’s priorities. We therefore have to position health both politically and economically as an essential, long-term investment.

Investing in systems for health helps to build resilience in Uganda

An important legacy of the fight against COVID-19 is the consensus that a lot more money needs to be directed towards strengthening systems for health, in order to build resilience and to prepare for the next crisis. For example, vaccines don’t deliver themselves, as Dr Seth Berkley reminded us. This may seem obvious, but it draws attention to the need for well functioning distribution systems and supply chains, which are in turn a core component of robust health systems that are able to get medicines, vaccines and other products to the people who need them.

Describing Uganda’s remarkable success in tackling COVID-19, an article by the Global Fund in March 2021 begins… ‘When a storm hits, it helps for your house to have a strong foundation’. Representing the Ministry of Health in Uganda, Dr Misaki Wayengera explained how, prior to COVID-19, several decades of health investments by the Global Fund, GAVI and G20 donors enabled the country to build strong, resilient health systems.

Rapidly deploying health infrastructure and community responses created to fight HIV, TB, malaria and other diseases, Uganda was able to roll out testing for COVID-19, making use of its network of laboratories and surveillance systems, backed up by well-trained human resources, including over 150 trained field epidemiologists spread throughout the country. These systems are once again proving critical as Uganda battles an outbreak of Ebola.

“Systems for health” rather than “health systems”

Peter Sands also pointed to the importance of language. In the Global Fund they talk about systems for health as opposed to health systems. When one hears the phrase ‘health system’, most people think about a publicly funded health facility which looks after sick people and makes them better again. Talking about systems for health brings in other actors, such as communities, the private sector, the research establishment, the ministry of education, and all the agencies which deal with animal health. As Peter said:

Talking about systems for health takes you away from thinking about health systems as fixing sick people to thinking about how to stop them from getting sick in the first place.

Peter Sands

This move towards a more holistic, planetary understanding of health is also high on Germany’s agenda. State Secretary Flasbarth cited the words of Chancellor Scholz, who is a strong believer in science and the interface between science and policy, saying, ‘never before did we have such strong interlinkages between health ministers and development ministers. As leader of the G7, Germany has shone a spotlight on the importance of the One Health approach, with the result that, as Secretary Flasbarth said:

Thanks to science, we really have the attention of high level politicians on the link between biodiversity loss, environmental destruction and health.

State Secretary Flasbarth

Communities play an essential role in prevention and preparedness

Systems for health place a much-needed spotlight on the role of communities, in prevention, preparedness and response to health and other crises. Dr Singh mentioned the millions of community health workers who were the bedrock of India’s response to the pandemic, and Rosemary Mburu pointed out, ‘prevention happens in communities, in households, when people gather at the chief’s camps under the trees, and when they go to the markets or places of worship. There is no better system than the community system for identifying people and ensuring we leave no one behind’.

Despite playing such a critical role in health systems and health security, Maelle Ba and Seth Berkely both raised the issue of the non-payment of salaries to community health workers and volunteers and called for global reforms so that their work is valued by finance ministries and other government stakeholders. Referring to community health workers as a fantastic but under-appreciated resource, Peter Sands asked:

Who better than community health workers to put money in the pockets of, if you want better health systems and broader socio economic development?

Peter Sands

Cooperation and multilateralism are key to fighting pandemics

Multilateral institutions such as Global Fund, GAVI and WHO not only help countries to build more resilient health systems, as in the case of Uganda, but also foster cooperation and collaboration. Support for multilateralism and cooperation are important pillars of Germany’s development cooperation. Peter Sands praised Germany for its leadership in global health, evidenced by the recently announced pledge of Euros 1.3 billion to the Global Fund’s Seventh Replenishment. 

As part of this commitment, Germany will give €100 million in the form of a debt-for-health swap, and Secretary Flasbarth pointed to the importance of this instrument given that indebtedness is another crisis afflicting so many low- and lower-middle income countries.

Germany is also the second largest donor to the COVAX facility and, earlier this year, hosted the 2022 COVAX Advance Market Commitment (AMC) Summit. Pledging €350 million for COVAX, as part of a broader US$1.22 billion funding package for the ACT-Accelerator, Germany has helped raise urgently needed funding to support lower-income countries to increase their vaccination rate and turn vaccines into vaccinations even in the most remote communities.

UHC should really be called TAX

However, as Peter Sands reminded us, the ultimate aim of multilateral institutions such as GAVI and the Global Fund should be to put themselves out of a job. Among other things, this requires domestic resource mobilisation in low-income countries, which is no easy task. With an ironic smile, Peter suggested that UHC should really be called TAX, saying, ‘unless and until countries put in place redistributive tax regimes and/or contributory insurance, they cannot achieve UHC. As multilateral institutions, we can nudge, incentivise, even push – but it’s fundamentally a political decision about what kind of society they want to build’. 

Let’s maintain (and even increase) investments in systems for health

Memories tend to be short and thankfully pandemics don’t happen all the time. If we are not vigilant, the world will retreat into a cycle of panic and neglect that characterised previous decades. Many countries increased their investments in health during COVID-19. Given increasing pressures on public budgets everywhere, against a backdrop of rising levels of poverty and inequality, and the ever more pressing issue of climate change, it is more important than ever that these investments in health are maintained, and are efficiently targeted. Panelists of the session all agreed that strengthening systems for health, and focusing on prevention and preparedness, as showcased by countries like Uganda, is the best use of scarce funds because resilient systems for health have a far better chance of weathering the crises which are sure to come.

Corinne Grainger
October 2022