Redesigning health systems for global heath security
Authors: Uzma Alam, Juliet Nabyonga-Orem, Abdulaziz Mohammed, Deborah R Malac, John N Nkengasong, Matshidiso R Moeti
Journal: The Lancet Global Health (2021)

Africa was predicted to be hardest hit by the COVID-19 pandemic, given its poor health systems. However, this outcome has not been the case. Despite the USA being the highest spender on health care globally,1Tikkanen R Abrams MK U.S. Health care from a global perspective, 2019: higher spending, worse outcomes?.https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019#:~:text=The%20U.S.%20spends%20more%20on%20health%20care%20as%20a%20share,higher%20than%20the%20OECD%20averageDate: Jan 30, 2020Date accessed: October 20, 2020Google Scholar COVID-19 has shown that its primary care infrastructure is in much need of strengthening. But we should not mistake COVID-19 as the biggest pandemic of our time. If anything, it is only a dry run, with other epidemics brewing on the horizon. Therefore, if the global community is serious about epidemic preparedness, global health security, and protecting the most vulnerable, we need to redesign health systems for resilience. Africa's lessons from the COVID-19 pandemic, as well as from concurrent outbreaks of cholera, Ebola virus disease, yellow fever, and chikungunya,2WHOAlert and response operations.https://www.who.int/csr/alertresponse/en/Date: 2020Date accessed: November 4, 2020Google Scholar could provide a roadmap. Building resilience needs adequate and committed investment in health through sustainable health financing. Furthermore, health system actors need to be aware of, and be able to anticipate, challenges, and so need to set aside reserve funds to ensure rapid response should disaster strike. To ensure proper financial accountability, health systems should be flexible enough to account for all resources, including emergency funding.3Nabyonga-Orem J Kwesiga B Abewe C Barroy H Tumusiime P Building sustainable health financing options for emergency response: lessons from the COVID-19 response in Africa.https://blogs.bmj.com/bmjgh/2020/05/26/building-sustainable-health-financing-options-for-emergency-response-lessons-from-the-covid-19-response-in-africa/Date: May 26, 2020Date accessed: November 4, 2020Google Scholar Most African countries set up special funds in response to the COVID-19 pandemic. Only four countries drew from reserve funds (Uganda, South Africa, Malawi, and Kenya). Effective epidemic detection and response are dependent on decision-makers having the right information via health information systems and data platforms; this structure is particularly important in resource-limited settings where there are often considerable variations in demand for resources, leading to wastage and suboptimal health outcomes. Efficient resource allocation is only feasible where there is good visibility across the health system's various components via quality health information systems. Such a system should be agile, equitable, and comprehensive. It should be built via decentralised open access data platforms that are guided by FAIR (ie, findability, accessibility, interoperability, and reusability) data principles, and accessible through sustainable data analytics marketplaces.4Wilkinson MD Dumontier M Aalbersberg IJ et al.The FAIR Guiding Principles for scientific data management and stewardship.Sci Data. 2016; 3160018Crossref PubMed Scopus (2978) Google Scholar In early 2020, 47 member states of the WHO African region adopted a strategy for scaling up health innovations in Africa. Examples of the use of big data in response to COVID-19 include WhatsApp chatbots in South Africa, self-diagnostic tools in Angola, contact tracing apps in Ghana, and mobile health information tools in Nigeria. Health policy needs to be informed by scientifically based evidence. This means investing in research and development upfront before an outbreak. Research and development should include a strategy to address gender differences in science, technology, engineering, and mathematics (STEM); at present, women represent 50% of the world's population, and yet globally they account for only 29% of such researchers.5UNESCO Institute for StatisticsFact sheet no. 55: women in science.http://uis.unesco.org/sites/default/files/documents/fs55-women-in-science-2019-en.pdfDate: June 2019Date accessed: January 16, 2021Google Scholar African efforts to address this imbalance have been ongoing at the regional level and country levels. Regional efforts include the establishment of the UN commission on the status of women, the Africa Union award for women scientists, the United Nations Educational, Scientific and Cultural Organization (UNESCO) STEM and gender advancement, the African Development Bank's gender equality index, The Boardroom Africa Initiative, and the Gender Summit Africa platform. Efforts at the national level have mainly been via developmental and poverty-reduction agendas and strategies. Innovation can support the adaptability and flexibility underpinning resilient health systems; an example of this is health systems that have built resilience through digital innovation such as telemedicine.6Bhaskar S Bradley S Chattu VK et al.Telemedicine as the new outpatient clinic gone digital: position paper from the pandemic health system resilience progam (REPROGRAM) international consortium (part 2).Front Public Health. 2020; 8: 410Crossref PubMed Scopus (30) Google Scholar COVID-19 has spurred innovation across Africa; out of 1000 new or modified technologies that have been developed worldwide to support different areas of the COVID-19 response, Africa accounts for 12·8%.7WHO AfricaCOVID-19 spurs health innovation in Africa.https://www.afro.who.int/news/covid-19-spurs-health-innovation-africaDate: Oct 29, 2020Date accessed: January 16, 2021Google Scholar A classic example of innovation in Africa is the partnership forged between local bottling plants and shopkeepers, who transport antidiarrhoeal kits to the remote areas of Zambia by packaging them in the empty space in Coca-Cola deliveries. Health system innovations should enable digital data collection, confidential self-reporting, and epidemic control measures such as health messaging, and they should aid investigation. Crucially, we should encourage reverse innovation; innovation can flow from low-income and middle-income countries to high-income countries, providing simple, low-cost solutions. To reach the full innovation potential, we need to challenge the idea that technical expertise flows in one direction only, and instead harness bidirectional expertise for resilient health systems. In Africa, community health workers are playing a pivotal role in the response to the COVID-19 pandemic where they are performing key response activities.8Africa CDC and Mastercard Foundation partner to deliver one million test kits, deploy 10,000 community health workers for COVID-19 response.https://africacdc.org/news-item/africa-cdc-and-mastercard-foundation-partner-to-deliver-one-million-test-kits-deploy-10000-community-health-workers-for-covid-19-response/Date: June 4 2020Date accessed: November 4, 2020Google Scholar Such workers, as trusted members of the community, form a quick link between clinical and community-based services necessary for effective outbreak response. Additionally, there is a need for a workforce development strategy that will address the labour shortage in critically needed fields. There needs to be a focus on human-centric policies that put people first; in the longer term, this pandemic response should call for strengthened engagement across borders to foster strong partnerships, as well as the reliance on local capacities. Within this supranational context, regional initiatives are needed to ensure that responses to a pandemic at country and regional levels are coherent and able to balance saving the lives and livelihood of all vulnerable people globally. With 70·8 million people having been forcibly displaced from their homes,9United Nations High Commissioner for RefugeesGlobal displacement.https://www.unhcr.org/ph/figures-at-a-glance#:~:text=War%2C%20violence%20and%20persecution%20drove,the%20course%20of%20a%20decadeDate: June 18, 2020Date accessed: November 5, 2020Google Scholar it is paramount that governments include marginalised communities, such as refugees, migrants, and internally displaced populations, in their policies and actions. All of the features mentioned need to be coordinated under strong national public health institutions to ensure lasting impact and country learning. Functional national public health institutions, working in close collaboration with international and local partners, can lead the country in the implementation of these measures, thereby coordinating the core public health functions of surveillance, laboratory networking, innovative information management, workforce development, management of an emergency operation centre, and conducting high-priority public health research.10Nkengasong JN Tessema SK Africa needs a new public health order to tackle infectious disease threats.Cell. 2020; 2: 296-300Summary Full Text Full Text PDF Scopus (4) Google Scholar COVID-19 has shown us that we must work collectively to ensure capacity globally. Without such global capacity, available to all, no country is safe from future pandemics. Despite the urgency to manage the immediate, medium, and long-term effects of COVID-19, it is key that we start now to identify and strengthen the critical characteristics of resilient health systems not just for emergencies but for health care in general. We posit that Africa provides multiple examples of these important characteristics. We declare no competing interests.