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A BRIEF ON THE WHO POSITION
Building health systems
resilience for universal
health coverage and
health security
during the COVID-19
pandemic and
beyond
A BRIEF ON THE WHO POSITION Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond
WHO/UHL/PHC-SP/2021.02 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: a brief on the WHO position. Geneva: World Health Organization; 2021 (WHO/UHL/PHC- SP/2021.02). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
iii
Acknowledgements
This position paper Reviewers and contributors from
was developed through WHO headquarters and regional
collaboration between offices: Pascale Abie, Hala Abou Taleb,
headquarters and all Benedetta Allegranzi, Sophie Amet,
regional offices of WHO, Roberta Andraghetti, Ali Ardalan,
under the leadership of Zsuzsanna Jakab Ian Askew, Anshu Banerjee, Anil
(Deputy Director-General, WHO) and Bhola, James Campbell, Alessandro
Mike Ryan (Executive Director, WHO Cassini, Jorge Castilla, Ogochukwu
Health Emergencies Programme) with Chukwujekwu, Giorgio Cometto, Peter
further guidance from Jaouad Mahjour Cowley, Sofia Dambri, Neelam Dhingra-
(Assistant Director-General, Emergency Kumar, Khassoum Diallo, Abdul Ghaffar,
Preparedness, WHO). Ann-Lise Guisset, Lynne Harrop, Qudsia
Huda, Humphrey Karamagi, Masaya
The responsible technical and Kato, Rania Kawar, Edward Kelley, Devora
coordination team comprised Sohel Kestel, Hala Khudari, Joseph Kutzin, Yue
Saikat, Marc Ho, Dheepa Rajan and Liu, Mwelecele Malecela, Paul Marsden,
Andre Griekspoor and was led by Suraya Robert Marten, Nikon Meru, Hernan
Dalil, Stella Chungong and Gerard Montenegro Von Mühlenbrock, Saqif
Schmets. Mustafa, Matthew Neilson, Hyppolite
Ntembwa, Denis Porignon, Adrienne
At the regional level, leadership and
Rashford, Tomas Roubal, Cris Scotter,
coordinated contributions were provided
Redda Seifeldin, Kabir Sheikh, Zubin
by directors and leads responsible for
Shroff, Ian Smith, Rajesh Sreedharan,
programme management, universal
Shamsuzzoha Syed, Regina Titi-Ofei,
health coverage and life course, and
Anthony Twyman, Jun Xing, Kenza
health emergencies: Natasha Azzopardi-
Zerrou, Yu Zhang, Zandile Zibwowa.
Muscat, Jarbas Barbosa da Silva (Junior),
Joseph Cabore, James Fitzgerald, Rana
Hajjeh, Melitta Jakab, Awad Mataria,
Pem Namgyal, Dorit Nitzan, Martin Taylor,
Prosper Tumusiime, Jos Vandelaer, Liu
Yunguo, Felicitas Zawaira.
© WHO / Lorenzo Pezzoli
Cover Photo: © WHO / Blink Media - Martyn Aim
iv
Key Messages For Heads of
Government, Ministries of
Finance and Leaders Outside the
Health Sectorv
• The health of populations is key • These reforms must integrate health
to economic development – a fact emergency preparedness and
recognized since the seminal World response systems into universal
health coverage efforts, based on
Bank report of 1993, Investing in
primary health care and essential
health (1).
public health function approaches,
• The catastrophic human, social with a reorientation of investment
and economic toll of COVID-19 has and resources.
demonstrated that protecting health
• National health security and
is also critical for economic security;
economic stability are also
just as economic development and
dependent on the protection of
health development are inextricably
populations living in contexts of
linked, so too economic resilience
fragility, conflict and violence.
depends on resilient health systems.
Governments must therefore ensure
• Governments have invested heavily dignified, equitable health services
in the COVID-19 response, and for marginalized and vulnerable
now face the challenge of fiscal populations during and beyond
pressures, managing heavy debt emergencies.
burdens with pressure to increase
• Such reforms, which build
taxation and reduce spending, while
all-hazards health emergency
sustaining social protection.
preparedness and resilient health
• Governments must avoid falling systems, generate a substantial
into the cycle of “panic then return on investment in terms of
forget”, frequently observed in past healthier populations, economic
pandemics. Increased investment resilience and equitable social
in emergency preparedness and development.
response has all too often been
followed by rapid disinvestment
and neglect, which weaken health
systems and undermine economic
resilience.
• Many countries will require
substantial health system reforms,
addressing foundational gaps in
public health capacities, including
the International Health Regulations
(IHR) (2005), to make them more
efficient, effective and resilient,
ensure economic resilience and
socioeconomic development, and
build trust.vi
© WHO / Oleksii Ushakov
Key Messages for Health
Leaders, Partners and
Communitiesvii
• The COVID-19 pandemic and its • increase and sustain adequate
catastrophic human, social and investment for health (including
economic toll have demonstrated the health system foundations
that making the health system and emergency preparedness
resilient to achieve universal health and risk management) and
coverage and health security must position health as central to
be a priority for every WHO Member socioeconomic recovery and
State. Universal health coverage and development;
health security are two sides of the
same coin and interdependent. • build a strong primary health
care foundation as the most
• Making a national health system cost-efficient and equitable
resilient requires: a high-performing way to achieve universal health
health system oriented to primary coverage and health security;
health care; the ability to sustain
essential health services for all, even • invest in essential public
during an emergency response; and health functions for holistic
investment in the essential public and sustainable public health
health functions, with emergency capacities at all levels of health
risk management for sustainable systems, including capacities
IHR (2005) capacities. required for all-hazards
emergency risk management;
• Adequate investment in health
emergency preparedness ensures • integrate health security,
that countries have the capacities emergency preparedness and
to prevent, detect and respond risk management requirementsi
to future health threats and in health system strengthening
emergencies. efforts, and vice versa;
• Making health systems resilient • invest in whole-of-society
and ready to address future threats governance with meaningful
requires substantial heath system engagement of communities,
reform in countries; this should be and civil societies, the private
backed up by a reorientation of sector and all line ministries;
investments and resources.
• pay special attention to those
• In view of the considerable damage who are disproportionally
that public health threats can affected by health emergencies,
inflict on national economies and for example, people in countries
population well-being, every WHO with contexts of fragility,
Member State Government should conflict and violence, as well
consider action to: as vulnerable and marginalized
groups in all countries, including
migrants and refugees.
i Including IHR 2005; the Sendai Framework for Disaster Risk Reduction, Paris Agreement on Climate Change and the
SDGs© WHO
1
Introduction for both robust health systems and
health emergency preparedness. Health
security cannot depend only on discrete
The widespread health preparedness and response functions;
and socioeconomic it also relies on a high-performing health
impact of the pandemic system, which can be drawn upon for
of coronavirus disease surge capacities without compromising
(COVID-19) on all aspects necessary services. Resilience relies
of society is by now well-documented on a system which constantly strives
(2, 3). Besides overall setbacks in to reach health system goals – service
progress made in achieving Sustainable access, quality, effectiveness and
Development Goal (SDG) 3 (Ensure financial protection, among others (5) –
healthy lives and promote well-being for even during times of crisis and sudden
all at all ages), the protracted disruption increases in health needs. At the same
of essential health services is threatening time, resilience also implies that action
future health outcomes in many places to achieve these health system goals is
(4). This comes on top of the struggle of more strongly underpinned by emergency
many countries to meet the increased preparedness and all-hazards risk
demands imposed by the pandemic management perspectives.
and conduct essential associated
public health functions such as contact- Health systems resilience is “the ability
tracing, quarantine and isolation. of a system, community or society
Some countries have faced concurrent exposed to hazards to resist, absorb,
health emergencies. Furthermore, new accommodate, adapt to, transform and
barriers to health care demand, such recover from the effects of a hazard in
as restrictions on movement, reduced a timely and efficient manner, including
ability to pay and fear of infection, still through the preservation and restoration
pose major challenges for health service of its essential basic structures and
utilization more than one year on from the functions through risk management” (6).
start of the pandemic. This is the case Health system resilience thus requires
despite the many innovative approaches the capacity to prevent, detect, respond
which countries have adopted to reduce to and recover from public health threats
disruption. One of the world’s biggest and emergencies and the agility to deploy
challenges in this crisis of unprecedented resources to meet the greatest needs and
proportions, as has been seen in maintain essential health services through
other health emergencies, remains its crisis periods.
hugely inequitable impact on vulnerable
populations and communities, both within
and between countries.
Objectives
The pre-existing inequalities causing Since universal health coverage and
COVID-19’s disproportionate effect health security are complementary
on both fragile countries and fragile goals, this position paper provides a
populations brings to the fore the need rationale and recommendations forBuilding health systems resilience for universal health coverage and health security
2 during the COVID-19 pandemic and beyond
building resilience and seeking integration
between promoting universal health
Universal health
coverage and ensuring health security by
the following means:
coverage and health
• recovery and transformation of
security: two sides of
national health systems through the same coin
investment in the essential public
health functions and the foundations Universal health coverage
of the health system, with a focus and health security are
on primary health care and the interdependent and
incorporation of health security complementary health
requirements; goals, and a strong
and resilient health system provides the
• all-hazards emergency risk
foundation for both. Health systems
management, to ensure and
built on a multisectoral, whole-of-
accelerate sustainable implementation
society approach are key to effective
of the International Health Regulations
management of all types of hazards. They
(IHR) (2005) and health emergency
enable existing capacities to address
preparedness;
increased health needs and underlying
• a whole-of-government approach to risks, ensure sustained delivery of high-
ensure community engagement and quality, safe essential health services even
whole-of-society involvement. during disasters and emergencies, and
build back better through the recovery
This brief calls for a renewed and period, making use of the lessons
heightened national and global learned. This requires proactive, system-
commitment to make health systems wide integration of universal health
resilient against all forms of public health coverage and health security efforts
threats for sustained progress towards at all levels of governance (national,
universal health coverage, health security subnational and community).
(including implementation of IHR (2005))
and the SDGs. The COVID-19 experience has shown
that critical health systems gaps and
vulnerabilities exist in countries from
all income groups. Reacting to health
emergencies as they occur, instead of
ensuring long-term health emergency
preparedness-building for health systems
resilience, has meant that countries
were unprepared for an emergency
of the speed, scale and severity of
the COVID-19 pandemic. It has also
shown that emergency preparedness
and response cannot be disentangled3
from other aspects of public health
– leadership, community engagement,
Primary health care
coordination mechanisms, action to
address inequalities, health care and
and the essential
health promotion. It has also shown up public health
market failures with regards to production
and allocation of essential supplies functions as a
and vaccines. Vertical investment and
programming within the health sector and foundation for
across sectors have proven ineffective
in enabling long-term health systems
universal health
development and resilience. Health
systems capacity for effective response
coverage and health
has also been hampered by ad-hoc security
and fragmented global cooperation and
coordination in the context of surveillance, A primary health care
flexible and deployable human resources orientation in health
and equitable access to infection systems, and the
prevention and control supplies and safe systematic integration
and effective medical products. of emergency risk
management within them, can provide the
The world has a window of opportunity to
essential foundations for both universal
learn from the COVID-19 pandemic and
health coverage and health security. The
build back better to create integrated
three key primary health care components
approaches for universal health coverage
of the Vision for primary health care in
and health security at an accelerated
the 21st century – integrated health
pace.
services including essential public health
functions; multisectoral policy and action;
and empowered people and communities
© WHO / Tom Pietrasik
(7) – are key levers where action is
needed to achieve both goals. For
example, integrated health services offer
a continuum of care across different sites
and levels and according to population
need (8). This also requires more
explicit integration of risk management
approaches, including anticipating surge
capacity for acute emergency services, in
addition to well laid preparedness plans
to ensure continuity of essential services
with adequate safety for staff and patients
in times of crisis (9). A multisectoral
approach is necessary to address publicBuilding health systems resilience for universal health coverage and health security
4 during the COVID-19 pandemic and beyond
health hazards beyond infectious disease been fragmented (14), resulting in historic
outbreaks effectively, such as industrial and ongoing underinvestment in primary
pollution, unsafe food or radiological health care and the essential public health
events; it is also the only way to address functions. The COVID-19 experience
the social determinants of health more has starkly revealed the vulnerabilities
broadly as an integral component of brought about by that underinvestment,
health systems strengthening in a way regardless of the income group of the
that also reduces risks for emergencies. country concerned. Even countries
Empowering communities implies health considered to have strong IHR (2005)
governance with a whole-of-society capacities and/or strong health systems
mindset, where people’s voices, including could not always fall back on sufficiently
those of vulnerable and marginalized robust public health and/or primary
populations, are systematically amplified health care capacity (15) with effective
through institutionalized participation governance. The need to prioritize
mechanisms which can be used in the primary health care and essential public
service of both emergency response and health functions has thus never been
day-to-day health sector operations (10). more acute.
The essential public health functionsii
include surveillance, governance Cost should not be a
arrangements, financing, health
promotion and risk reduction, health barrier
legislation, public health research and
human resources (11). These functions The cost of ensuring
are necessary to underpin strong universal health coverage
primary health care; action in these and health security is
areas ensures that both health systems extremely low compared
strengthening and all-hazards emergency with the cost of a crisis
risk management also serve as means of such as the current pandemic or future
achieving universal health coverage and threats, including climate change (1, 16,
health security (12, 13). 17, 18, 19). Further estimates concur
that improving emergency preparedness
Despite this inherent interdependence is very affordable, with estimates ranging
and overlap in the actions needed to from US$ 1 to US$ 5 per person per
achieve resilience, the approach to date year (20) – which will pay for itself several
at both global and national levels has
ii The essential public health functions are a list of minimum requirements for Member States to ensure public health.
These focus on health promotion, prevention, determinants and security. They include aspects such as surveillance
and monitoring, public health workforce, governance, regulation and public health legislation, public health systems
planning and management, public health research, social mobilization and participation, preparation and response to
health hazards and emergencies and promotion of health and health equity. The essential public health functions have
recently been referred to, from an economic perspective, as “common goods for health”. See: Common goods for
health. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/health-
topics/common-goods-for-health#tab=tab_3, accessed 24 June 2021).5
times over because of the significantly 1. Leverage the current response
lower costs incurred when emergencies to strengthen preparedness
do happen. Moreover, a 1% additional against future threats and health
allocation of gross domestic product systems towards resilience.
to primary health care will enable most This involves using the results of
countries to bridge current coverage gaps multisectoral reviews and intra-action
(21). This means that financial cost should and after-action reviews to inform
not be a barrier that prevents countries sustained investment in emergency
from investing in building resilience; preparedness, the IHR (2005)
in the end, the dividends gained by capacities and their functionality,
addressing universal health coverage and determining priority needs, and
health security simultaneously leave us embedding policies and national plans
collectively better off, making it a wise of action for health security in health
investment from both a financial and a system strengthening. It ensures
health and well-being point of view. population access to quality health
services while maintaining capacities
for emergency preparedness. It
Policy includes harnessing investment for
medium- to long-term recovery,
recommendations preparedness and resilience against
all types of hazards. Implementation
WHO calls on countries of IHR (2005) must remain a
to take action for recovery requirement for health systems
and transformation of their resilience.
national and subnational
health systems and 2. Invest in essential public health
proposes the following interconnected functions at all levels of health
policy recommendations and actions systems, including those needed
to inform planning, investment for all-hazards emergency risk
and interventions by all relevant management. Critical and chronic
stakeholdersiii. When implementing these gaps in essential public health
recommendations, countries should functions should be the target of
apply an integrated approach, taking intensified investment.
into consideration the heterogeneity
within and between countries, and the 3. Build a strong primary health care
complementarity between the various foundation by ensuring political
concepts covered. commitment and leadership to place
primary health care at the heart
of efforts to attain universal health
coverage, health security and the
SDGs.
iii A more detailed version of the recommendations and actions is contained in the WHO position paper Building health
system resilience towards universal health coverage and health security during COVID-19 and beyond.Building health systems resilience for universal health coverage and health security
6 during the COVID-19 pandemic and beyond
4. Invest in institutionalized disaggregated data, to inform
mechanisms for whole-of- policies, planning and investment
society engagement. Long-term globally, with a focus on marginalized
commitment will be required to and vulnerable populations within
bring about a real shift in the modus and beyond countries with fragile,
operandi of emergency preparedness, conflict-affected and vulnerable (FCV)
emergency risk management and settings.
maintenance of essential health
services, which are essential for
functional health systems and public Enabling
health operations with more inclusive
participation. implementation with
5. Create and promote enabling shared responsibility
environments for research,
innovation and learning by finding The above
ways to maintain and adapt the recommendations
innovative models implemented highlight the need
during the pandemic, thereby for coordinated,
increasing the ability to handle the multisectoral, whole-of-
demands of future threats and society action with clear government
emergencies. ownership.
6. Increase domestic and global WHO will collaborate with its Member
investment in health systems States, the United Nations and other
foundations and all-hazards partners to ensure synergies with
emergency risk management: existing and upcoming national and
this includes prioritizing investment global effortsiv. At national level, WHO
and financing for public health and and its partners will similarly support
health security, with consideration for bolstering whole-of-society, government-
countries with protracted instability led socioeconomic recovery and
and fragile systems. transformation processes. This will
include support for bringing together
7. Address pre-existing inequities various line ministries, development
and the disproportionate impact partners, civil society, the private sector
of COVID-19 on marginalized and communities to promote the health
and vulnerable populations by, agenda and mobilize resources for a
for example, monitoring inequities primary health care oriented path towards
in health and access to care, using universal health coverage and health
iv Access to COVID-19 Tools (ACT) Accelerator; United Nations framework for the immediate socio-economic response to COVID19;
SDGs; IHR (2005); the Sendai Framework for Disaster Risk Reduction; Paris Agreement on climate change, Universal Health
Preparedness Review.7
security. WHO will advocate for and in health systems recovery and building
highlight the key roles of all stakeholders resilience and better preparedness
in ensuring increased investment for following emergency response efforts.
health as a priority development agenda This will only happen if all sectors
across various sectors. collaboratively position health as central
to national development.
An intensified focus on vulnerable and
marginalized populations in all countries,
and especially in FCV settings, is This brief provides a
necessary to address the vast global succinct, policy-oriented
and intra-country inequalities exposed
summary of the WHO
by the pandemic. WHO is committed to
working with Member States and partners position paper on building
to support countries with FCV settings health system resilience
in addressing critical foundational health
during COVID-19 and
systems issues and operationalizing the
humanitarian-development-peace nexus. beyond, developed
in consultation with
The expected result of such a series of
actions and commitments is health
WHO regional offices
systems which are more resilient to future and headquarters. The
shocks in terms of maintaining quality policy implications
essential health services with financial
protection while ensuring that
and recommended
governments and communities are better actions are targeted
prepared to prevent, detect, manage and at a broad audience of
respond to health threats, including
providing scalable surge capacity to meet
policy-makers with a
health emergency needs. view to their ongoing
The aim is thus to avoid a repeat of
role in the COVID-19
the challenges and gaps of the past response, health systems
and ongoing emergency experiences, strengthening, health and
including the lack of adequate investment
socioeconomic recovery
and national development.
© WHO / PAHOBuilding health systems resilience for universal health coverage and health security
8 during the COVID-19 pandemic and beyond
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