Correspondence

Global Health & Medicine. 2024; 6(4):251-255.
DOI: 10.35772/ghm.2024.01035

Strengthening health systems during non-pandemic period: Toward
universal health coverage in the pandemic agreement
Yuta Yokobori*, Ikuma Nozaki, Masahiko Hachiya, Masami Fujita, Yuriko Egami, Shinsuke Miyano, Mari Nagai,
Kenichi Komada, Masataro Norizuki, Yasunori Ichimura, Motoyuki Tsuboi, Nobuyuki Kawachi, Shunji Takakura
Bureau of International Health Cooperation, World Health Organization Collaborating Center for Health Systems Development, National Center
for Global Health and Medicine, Tokyo, Japan.

Abstract: Reflecting the experiences of the COVID-19 pandemic, the global response was reviewed by the
Independent Review Panel for Pandemic Preparedness and Response. Based on the panel reports, the World HealthOrganization (WHO) member states decided to establish the intergovernmental negotiating body for drafting a WHO
convention, agreement or other international instrument on pandemic prevention, preparedness and response, aiming
for approval at the 77th World Health Assembly in 2024 (May 27- June 1). Amidst this process, the National Center for
Global Health and Medicine, Japan (NCGM), as a global health organization focusing on health system strengthening
in low- and middle-income countries, from the perspective of Universal Health Coverage (UHC), provided technicalinputs to the representatives of the Japanese government. This paper summarizes crucial aspects of the NCGM inputs,
including maintaining essential health services delivery during a pandemic, responding to evolving demand of healthworkforce, and ensuring the equitable distribution of pandemic products. These aspects can contribute to not only
strengthening health crisis response and preparedness, but also achieving UHC. Therefore, the concerted efforts
focusing on UHC and health crisis could yield synergistic effects. In addition, another aspect stresses the importanceof social protection systems beyond health sector to reach vulnerable populations experiencing hardships during
the COVID-19 pandemic. Since the whole-of-government approach including social policies is covered in the draft
pandemic agreement, it is hoped that the upcoming pandemic agreement will trigger each member state to expand thescope of health crisis management beyond the health sector.
Keywords: pandemic agreement, UHC, IHR, Health Security

Introduction
Since the first COVID-19 case was reported in China in
December 2019 (1), SARS-CoV-2 rapidly spread aroundthe world, leading to a declaration of "pandemic" by theWorld Health Organization (WHO) Director-Generalin March 2020 (2). Subsequently, continuous spread of
the virus caused significant socio-economic losses andimpacted non-COVID-19 health services worldwide.
Responding to the resolution of 73rd World Health
Assembly (WHA) held in 2020, the independent panel
for pandemic preparedness and response (IPPPR)
was organized to review the WHO's response (3).
Six months later, the IPPPR compiled the reports (4)during the 2nd Special WHA in December 2021, leading
to the decision to establish the inter-governmental
negotiation body (INB) to draft and negotiate a WHO
convention, agreement or other international instrument
on pandemic prevention, preparedness and response,
aimed for approval at the 77th WHA in May 2024 (5).

Subsequent intermittent meetings of INB organized thediscussions on the agreement draft, culminating in thesubmission of the Negotiating Text in October 2023
(6), followed by the Revised Negotiating Text in March2024 (7). Then, the outcome of INB including texts
still under negotiations was submitted to the 77th WHA(8) for further consideration as a legally binding policy
document covering comprehensively a wide range ofitems (e.g. strengthening health systems, manufacturing
and access to related medical products, fundraising,and societal efforts beyond health), which after all, wasagreed to extend the negotiation period for up to one
year.
Throughout this process, we, the Bureau ofInternational Health Cooperation, the National Center
for Global Health and Medicine, Japan (NCGM), as a
global health organization focusing on health systemstrengthening in low- and middle-income countries(LMICs) with the aim of Universal Health Coverage(UHC) achievement, have provided technical inputs to(251)

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Table 1. Crucial aspects of health system strengthening to be addressed from perspective of UHC in preparation for future
pandemic and related article of negotiating text at 77th WHA
Addressing the "resilience" of health systems to the challenges clarified after the pandemic• Strengthening service delivery that does not cease even during a pandemic by‒ Developing the service continuity plans during pandemic and the simulations,‒ Strengthening health information system to capture health resources and utilization of those,‒ Leveraging lessons learned from previous pandemic and other emergency events, including community systemor digital health.

Article 6• Responding to evolving demand of healthcare workforce by‒ Providing opportunities to learn the basics of pandemic response and preparation,‒ Maintaining a surplus of workforce capacity during non-pandemic period to handle the pandemic response,‒ Building the capacity for community engagement, aligning with Primary Health Care oriented system.

Article 7• Enhancing the domestic logistics for equitable distribution of pandemic products by‒ Assessing the capability of domestic supply chains, including the cold-chain system, regularly for further strengtheningof the absorption capacity,‒ Considering the reduction of medical waste and the cost burden of waste disposal.

Article 13

Establishment of social protection system beyond the health sector to protect people's livelihoods even in times of city
lockdowns and other social countermeasures• Strengthening resident registration system such as Civil Registration and Vital Statistics, national ID,• Having mechanisms and legal frameworks for social assistance as part of routine surge financing for health crises,• Enhancing coordinating mechanisms involving stakeholders across sectors during pandemic.

the representatives of Japanese government participatingin INB meetings, drawing on our longstanding
experience and accumulated knowledge (9). Based onthese experiences, at the time of the 77th WHA in 2024
(May 27- June 1), we summarized here crucial aspectsof health system strengthening in preparation for future
pandemics which are to be addressed particularly in
LMICs from the perspective of UHC (Table 1).
Addressing the "resilience" of health systems to thechallenges clarified after the pandemic
Strengthening service delivery that does not cease evenduring a pandemic
The experience of COVID-19 pandemic highlighted
the importance of ensuring uninterrupted essential
health services during health crises. In fact, during the
pandemic, routine immunization programs have been
delayed in many countries, leading to outbreaks ofvaccine-preventable diseases (10). Considering thesepoints, while the negotiating texts at the 77 th WHA
includes provisions regarding the maintenance of healthservices in Article 6, it does not mention the specificstrategies. Such strategies are shown as follows.
First, development of emergency response plans
during the non-pandemic period including service
continuity plan should be highlighted to ensure
uninterrupted essential health service delivery evenduring a pandemic. Based on the plans, regularsimulations and training exercises should be also
considered to provide more concrete knowledge andskills for the participants. Regarding the measures of

Article 17

the plan, there is potential to leverage lessons learned
from efforts in response not only to pandemics but also
to natural disasters, extreme weather conditions, andgeographically isolated islands, which may be related
to climate change. The applicable interventions may
include multi-dose prescriptions for chronic diseases,
mobilizing community systems through collaboration
with civil society organization (CSO) / community basedorganization (CBO), and clinical monitoring via digitalplatforms.
Second, strengthening health information systems,
including health information not directly related topandemic diseases but to health resources, is crucial
to maintain effective health service delivery as wellas to monitor epidemic situations and intervention
results. Information about resources such as healthworkforce, health facilities including equipment, andpharmaceuticals, utilization of those and the quality ofservices should be helpful to efficiently and effectively
distribute limited resources to areas with high potential
demand. Information, such as high-care unit bed
occupancy, will also be important for triangulation of
epidemiological information in the early stages of apandemic when disease definition is not clear.
Some existing global guidance, for instance, in thefield of human resources for health workforce cover theactivities to maintain essential health services during
health crises, including monitoring and evaluation of
the implementation status (11). It is hoped that WHO
will leverage these relevant documents to support eachmember state to implement the pandemic agreement.
Responding to evolving demand of health workforce(252)

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While Article 7 already addresses this issue, it isimportant to reiterate the significance of the healthcare
workforce. The pandemic has highlighted quantitativeand qualitative shortages of health workforce, regionaland occupational disparities in distribution and retention,
constrained labor markets, and vulnerable pre- and inservice training systems (12). Wide ranges of healthworkforce challenges have already been analyzed since
the pre-pandemic period. Nonetheless, health workforce
attrition and shortages would continue over the postpandemic period and could destabilize the health systemitself. Without solid and effective measures, preparedness
and response to any future health crisis would be
impossible (13-15).
What is needed for the health workforce to respondto crisis are: i) providing all health workforce with
opportunities to learn the basics of pandemic response
and preparation such as surveillance, early detection of
diseases, infection prevention and control (IPC), throughincorporation into pre- and in-service training during
the non-pandemic period, and ii) maintaining a surplus
of workforce capacity during the non-pandemic period
even when it overlaps with regular duties, to ensure
resilience to handle the pandemic response. Aligning
health workforce policies with the Primary Health Care
(PHC) oriented system (13) is particularly essential toprovide necessary health care to the vulnerable or the
hard-to-reach population to achieve UHC, even during
the health crisis. Such a policy example is to invest in
multidisciplinary PHC teams with optimized skill mix,
adjusted scope of practice, and support with digitaltechnologies, as well as enhanced collaboration with
CSO/CBO to gain community engagement. Such PHC
oriented systems can also contribute to early detection
and risk assessment during a future pandemic.
At both national and local levels, capacity-building
for health work force, including community engagement,
becomes particularly important. Since the activities bygovernment could not cover both responding to heathcrisis and ensuring essential healthcare services at thesame time, collaboration with community through CSO/
CBO should be emphasized as surge capacity to increase
the likelihood of necessary service delivery to unreachedpopulations. It should be important to collaborate with
communities and strengthen their capacities during a
non-pandemic period.
Equitable distribution of pandemic products
While the negotiating texts of pandemic agreement at the77th WHA emphasized the various items related to theequitable distribution of pharmaceuticals, particularly"pandemic products", during health crises, such astechnology transfer, diversified manufacturing on aregional basis, global supply chain networks, and rules
for international allocation, we would like to emphasize
more on the importance of domestic supply chains ineach country. The ability of regular medical supplies will,of course, greatly affect the ability to supply pandemic
products in an emergency. During this pandemic, someof the COVID 19 vaccine required ultra-low temperaturestorage & transport for vaccines, ultra-cold chain,that posed challenges to supply chain infrastructuredevelopment in various countries, particularly countries
with challenges in the cold chain of regular vaccines,
highlighting the importance of maintaining cold chain
logistics during the non-pandemic period. Anotherexample is the absorption capacity of pandemic product,
which is often in large volumes. Where supply chainsare fragile, large quantities of donated pharmaceuticals
might not be kept up by domestic supply, resulting inpharmaceuticals being wasted. Therefore, in addition
to strengthening supply chains, it is necessary tothoroughly assess the absorption capacity of recipient
countries before distributing aid supplies. While Article
13 mentions these points, it is important to re-emphasize
the importance of domestic supply chain development
during the non-pandemic period to ensure that essential
medical products reach vulnerable populations in needduring health crises.
In addition, addressing pharmaceutical medical
waste is also essential. While Article 13bis mentions
coordinating expiration dates, product usability, andthe availability of related auxiliary products between
recipient countries and supporting agencies to reduce
medical waste, there is still a possibility of generating acertain amount of medical waste during emergencies. In
such cases, considering the cost burden of waste disposalon the recipient countries becomes important, thus
necessitating consideration of the cost burden of medical
waste disposal.
Establishment of social protection systems beyond thehealth sector
During the COVID-19 pandemic, particularly vulnerable
populations experiencing economic and psychologicalhardships due to measures like lockdowns resulted in
low utilization of health services and deterioration ofhealth. This highlighted the importance of broad-ranging
measures beyond the health sector. For instance, it is
crucial to identify who among the population is mostvulnerable during a health crisis and maintain informationon them during the non-pandemic period. Systematic
understanding data such as residential registration, civil
registration and vital statistics (CRVS), national IDs,and poverty status allows for the prioritization of social
protection measures for impoverished individuals andhouseholds during pandemics. As Article 6 addresses
such information systems, it is important to note its
significance in response, including investigation of thetarget populations, implementation and monitoring of
measures like vaccination campaigns. Furthermore, incountries where CRVS systems are fragile, it is important(253)

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to acknowledge those who may fall through the cracks ofnational ID systems. Governments should engage nongovernment actors through social contracting agreements
to proactively identify vulnerable populations and ensurethat pathways for delivering support are in place.
Additionally, during social measures such as
lockdowns, protecting the livelihoods of vulnerable
populations becomes crucial for effective healthcare
responses during health crises. Social security systems
for vulnerable populations are important from theperspective of UHC (16). In this pandemic, countries
that implemented cash transfers to support vulnerable
populations during lockdowns protected their health.
Having mechanisms and legal frameworks for social
assistance like cash transfers as part of routine surge
financing for health crises allows for their utilization
during emergencies (16,17). While Article 17 mentions
such comprehensive social efforts, it is important to also
consider social protection systems that function during
health crises. Organizations like the ILO, UNICEF, and
the World Bank are also working on social protection
during health crises (16), and active collaboration withthe healthcare sector, particularly WHO, is desirable.
Furthermore, coordinating mechanisms involving
stakeholders across sectors are crucial. During healthcrises, various actors beyond the healthcare sector,
including government ministries, civil society, othercountries' governments, and international organizations,
are involved. Understanding the strengths and limitationsof each organization's support and effectively deploying
resources for pandemic response requires coordination.
For instance, establishing inter-sectoral coordination
mechanisms like Public Health Emergency Operation
Centers or Emergency Medical Team Coordination
Cells during disasters involving multiple sectors
becomes essential for pandemic response (18,19).
Handling the complex coordination of different actors
during pandemics may necessitate setting up domestic
coordination mechanisms and conducting simulations
and training during the non-pandemic period. In thisregard, the upcoming pandemic agreement is expected tocover these elements.
Based on the drafts of the WHO convention,agreement and other international instruments on
pandemic prevention, preparedness and response(6-8), vital points requiring further consideration,
which each member state, especially among LMICs
with weak health systems, has to address as part oftheir preparedness for future pandemics have beensummarized. All the aforementioned aspects discuss
activities aimed at delivering quality essential healthcare
services during the non-pandemic period to all people,
including vulnerable groups, and toward achieving
UHC, highlight how these activities contribute toeffective health crisis management. Furthermore, during
the COVID-19 pandemic in Japan, activities such as
establishing medical response teams for patients unable

to visit hospitals during lockdowns were observed. Such
health crisis measures have the potential to enhance awide range of healthcare services contributing to UHC,
including addressing aging and non-communicablediseases. Thus, activities supporting health crisis
management and UHC are strongly interrelated, andconcerted efforts focusing on both could yield synergistic
effects. Expectations are for the pandemic agreement toprovide a legal framework for both achieving UHC andadvancing global health security together. Additionally,in order to reach vulnerable populations experiencing
hardships during a pandemic, this article stressed theimportance of not only health system strengthening, butalso a social security system beyond the health sector.
Since a whole-of-government approach including social
policies is covered in the draft pandemic agreement, it
is hoped that the upcoming pandemic agreement will
trigger each member state to expand the scope of healthcrisis management beyond the health sector.
Funding: This research was supported by the NCGM
Intramural Research Fund.
Conflict of Interest: The authors have no conflicts ofinterest to disclose.
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---Received May 23, 2024; Revised June 10, 2024; Accepted June
13, 2024.
Released online in J-STAGE as advance publication June 16,
2024.
*Address correspondence to:
Yuta Yokobori, Bureau of International Health Cooperation,
National Center for Global Health and Medicine, 1-21-1
Toyama Shinjuku-ku, Tokyo 162-8655, Japan.
Email: y-yokobori@it.ncgm.go.jp(255)