Abstract
Equity and Global Security Require a Robust Health System
A functioning health system, according to the World Health Organization (WHO), envisages improving the health status of individuals and communities, defend against health threats and protect people against the financial consequences of ill health (WHO, 2010). It does so by providing equitable access to people-centred care, by empowering communities to fully participate in the decisions that affect their health.
Simply put, the health system enables organisations, institutions and individuals to promote health, prevent diseases and ensure quality of health service delivery (WHO, 2007). A health system based on primary health care can fulfil the dreams and commitments that for many decades have been eluding a great majority of people in our society. Given that health is a result of interplay of various factors, the social and economic determinants of health must also be addressed, thereby calling for inter-sectoral action to achieve various health outcomes and results.
In the current context of COVID-19 pandemic, the experiences in many countries show that early and decisive response requires unprecedented mobilisation of health systems (Narain et al., 2020; WHO Europe, 2020). Countries at early stages of disease transmission still have an opportunity to prepare their health systems to mitigate the health and economic impacts of the pandemic.
Of course, a resilient health system is essential beyond the coronavirus crisis, as stated by WHO Director-General, Dr Tedros Adhanom Ghebreyesus: ‘Strong and resilient health systems are the best defence not only against outbreaks and pandemics, but also against the multiple health threats that people around the world face every day’. The components of the health system comprise ‘the foundation of global health security’ (WHO, 2020, May 6).
Over the past 60 years, world leaders have made many commitments and statements, but little progress has been made in achieving health equity and universal coverage. According to a United Nations (UN) estimate, more than 5 billion people would lack access to essential health services by 2030 (WHO, 2020, April 6). Those services include the ability to consult a health worker and access to essential medicines and running water in hospitals.
Access is further complicated by a shortage of trained healthcare workers. Besides doctors, the 2020 State of the World’s Nursing Report found, the world would need 6 million more nurses by 2030 to reach global health targets (WHO, 2020, April 6). Shortage of healthcare workers is felt most acutely in low- and middle-income countries. As the world witnesses unprecedented political commitment to universal health coverage (UHC), one may wonder how UHC can be achieved without the requisite health workforce.
As these dangerous public health gaps and disparities between rich and poor countries and urban and rural areas continue to exist, they do not just undermine the health of individuals, families and communities but also put global security and economic development at risk.
In fact, a former minister in the central government in India famously stated in 2012 that India’s public health system had collapsed (NDTV, 2012). Unfortunately, however, in spite of this acknowledgement, not much was done to alter or improve the situation.
There is therefore an urgent need to define and implement a policy that can bring about a large-scale health system transformation and result in a health system that is strong and resilient and which can form the backbone of all programmes, be they pertaining to communicable/non-communicable diseases or to maternal and child health—a health system that can sustain the gains achieved so far.
Policymakers must realise that a strong and well-functioning health system is an investment for the future which would enable efficient use of scarce resources, especially in low- and middle-income countries. Kerala is a good example that shows that if one invests in a public health system that has the faith and trust of the people, it is possible to respond effectively to any challenge. It is no surprise that Kerala is presently the only state in India which at the early stage of pandemic was able to flatten the COVID-19 curve (Biswas, 2020). In contrast, places like Mumbai and Delhi face a high incidence of COVID-19 and have inadequate response, because of the fragmented health system and poor coordination, in part due to the multiplicity of providers.
A robust health system can fulfil the promises of equity, solidarity and justice which presently remain an unfulfilled project. Let us address the major gaps in public health investment which are undermining health and welfare around the globe. Let us not accept persisting inequalities in the levels of health and healthcare within countries and between countries and orient our health systems towards universal coverage with equity, solidarity and inclusion. According to WHO, the difference between a health system that works well and one that does not can be measured in death, disability, impoverishment, humiliation and despair (WHO, 2020). A paradigm shift in the former calls for a change for the better. As Einstein once said, ‘Do not pretend that things will change if you keep doing the same all the time’.
Let us address the issues of the health workforce and research and information system, critically important for decision-making, and ensure equitable access not only to health technologies but also to the necessary know-how, which aligns with our principles of equity. Recognising that health systems alone cannot solve all social problems of justice and equity, let us build partnerships but try also to mend the fragmented health system with passion and human creativity. The time has come to challenge the paradox that while health has risen to prominence on the international development agenda, within most countries health matters are often afforded lower priority than the concerns of other sectors (WHO, 2013).
Finally, on a personal note, after having worked on vertical programmes all my life, first on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis and other communicable and non-communicable diseases, over the past 32 years, I now realise more than ever before how important the health system is. In my viewpoint, the health system is essential not only for delivery of health services with equity and quality but also to ensure sustainability of services offered through various programmes. I am therefore very grateful to Dr S. D. Gupta, Chairman, IIHMR University and editor of the Journal of Health Management and SAGE Publications for inviting me to guest-edit a special issue of the Journal of Health Management on the critically important issue of ‘Health Systems’. I am extremely thankful to the eminent experts of national and international repute for contributing to the special issue.
I hope the readers will find the issue useful. We look forward to your comments.