Civil society calls for health for all at multistakeholder...
By Benjamin Rouffy-Ly, Consultant, WHO; Godelieve Van Heteren, Senior international consultant health & social systems transformations; Benjamin Downs Lane, Health Systems Advisor WHO.
To learn meaningfully from the pandemic and give everyone, everywhere a better chance of good health and well-being, what big changes must we all demand? In the many transformative health system governance debates triggered by the current pandemic, three fundamental considerations have surfaced time and again. In line with initiatives such as Reclaim Comprehensive Public Health and the Elders’ December 2020 report "Build Back Better for Universal Health", a consensus is emerging that now is the time to (1) revisit our public health systems and prepare for the future; (2) prioritize universal health coverage at national and global levels; and (3) promote healthier societies via holistic policies and inclusive social development.
Since March 2020 the Health Systems Governance Collaborative has contributed to these debates through the Building the Reset Initiative. Here are our key takeaways on how to advance these three agendas.
Prepare public health systems for the future: deliver on common goods for health
As a matter of urgency, societies should address the chronic under-provision of Common Goods for Health, those goods that the market can not sufficiently provide but which have major impacts on health. Most essential public health governance functions, such as regulations and basic surveillance systems, fall into this category and are an important part of a health system adequately prepared for crisis responses.
The current pandemic has unequivocally proven what has been said for decades: the cost of providing common goods is by far inferior to the cost of facing a pandemic (or any other crisis) unprepared. But because the cost of common goods was more tangible than benefits that may only be noticeable in the longer term, many governments have felt little incentive to provide them.
Salience is an important ingredient of successful collective action, and “health” has seldom been more salient. Now is the time for societies to demand the provision of common goods for health which are key for health systems being fairer and adequately prepared for future health threats. This would require recognizing that these common goods for health, for the most part, require multisectoral action and a broader approach to health and its determinants. We now see this emerging in one health, planetary health and WHO’s ‘green recovery’.
Prioritise universal health coverage at national and global levels: build from the ground up and go beyond the health sector
In this crisis most governments have resorted to centralized and unilateral decision-making and large-scale coercive measures. While strong leadership is needed in times of crisis, insufficient citizen engagement has undermined trust, which in some cases was already eroded and fragile due to not-always-beneficial histories of prior engagement. This had a negative impact on the acceptability of public health measures. Faced with impossible choices and no optimal option, actively turning to communities would have allowed leaders to discuss different sub-optimal options and collectively imagine solutions and compromises better suited to local contexts, while minimizing their negative impacts.
Our deliberations have underscored that there are immense resources in communities in terms of knowledge, capacities, agility, and ingenuity. Local CSOs and networks were often the first to propose actionable solutions and assistance to the vulnerable during this pandemic. Empowering people and communities to be able to be actors of their own health, and examining decentralization processes to match capacities and responsibilities and strengthen autonomy, could prove highly beneficial to making progress towards UHC and the Sustainable Development Goals (SDGs) in general.
The language of the SDGs can be a powerful tool to hold our governments accountable and our collective efforts aligned. Continued efforts to translate the SDGs to local operationalization and understand how they relate to the daily concerns of people are needed. In all country contexts, being able to articulate what moving forward with the SDG agenda would mean for our daily lives, and how our behavior can have an impact on it, can help us remember that we too are actors of their realization.
More broadly, the crisis has shown how all our lives are interconnected. This sharp awareness can help us to finally adopt the often proclaimed ‘broader approach’ to health systems that acknowledges the importance of social, environmental, and commercial determinants of health and openly recognizes that health outcomes depend on so much more than healthcare per se.
Whole-of-government approaches urge siloed bureaucracies to learn to plan and implement together. Whole-of-society approaches depend on the capacity of governments to find ways to engage with societies meaningfully, sustain dialogues with multiple stakeholders, including the private sector and - most of all - the people. Many have advocated these approaches before. Now is the time to move these agendas.
Promote healthier societies through holistic policies and social development: decide together and put health first
The inherent political nature of the COVID-19 response has in some cases led to forms of ‘instrumentalization of science’ – conscious or unconscious choices about how, and which, “science” and “scientists” inform and justify policy – that have undermined evidence-based decision-making. The science-politics interactions are complex and often lead to dilemmas. In some places, politicians have used reference to ‘science’ to deflect part of their own responsibilities. In other cases, central authorities decided too much alone, as a recent mapping of the governance response shows. Going forward, leaders need to (1) broaden the science base for policy-making, (2) strengthen overall participation, and (3) take clearer responsibility for their choices:
- COVID advisory bodies are able to give the most comprehensive and context-relevant guidance when composed of experts from diverse biomedical and social science disciplines, paying attention to how policy recommendations may impact different groups with different vulnerabilities.
- Policy-making is more robust when developed through inclusive and participatory processes that pay attention to the fears and anxieties of the people. This is especially the case when considering measures that limit individual freedoms, may involve important trade-offs, and have very different impact on different parts of the population.
- Science is not a substitute for policy-making. Leadership is about considering the evidence, consulting diverse stakeholders, and ultimately making a choice, communicating it clearly and with compassion, and taking responsibility for it.
Pandemic responses in some countries have seemed reactive, narrowed by a specific biosecurity focus, and informed mostly by the predominant biomedical approach to health systems. In the longer term this will not do. To view health as a state of well-being and not just the absence of disease, we need to renew our commitment to health systems that go beyond health care, and comprehensive public health that is both reactive and proactive.
Finally, the pandemic and responses have exacerbated social divisions and created new ones: health workers vs. others, wage workers vs. middle class and elites, those who can work from home vs. those who can’t... How can we build social cohesion and social inclusivity, and make health, and strengthened health systems, a central part of our societies? Fairer and more inclusive societies should be a goal in and of itself, as well as a prerequisite to health for all. It has been made clear than none are safe unless all are safe, and global equity, social and health justice constitute the only path forward to achieve genuine ‘security’ and a sustainable future. How can we recognise ‘health’ as fundamental in international relations? We are all interdependent: and health is about all the factors that link us to each other and our surroundings.
A vision for the future
A year of collective deliberation has strengthened many people’s resolve to work forwards fairer, more inclusive and more resilient societies. As humans, we can and must adapt. We can and must use the crisis to build a collective awareness and consciousness of what is needed for our societies. We must sustain our efforts, overcome resistance to change, and demand inspiring leadership and inclusive governance.
A year of Building the Reset exchanges has left us with optimism. Drawing on our collective experiences and thinking, we can shift gears, create the sustainable future that we so desperately need and draw up the clear and practical roads to get there. We are all implicated in this global crisis. We are all actors in the redefinition of what are acceptable social contracts, from the local to the global level. We can all put our energies into alternatives that work.
The Health Systems Governance Collaborative will therefore continue to promote these conversations and identify actions to bring about meaningful change. To get involved, join our web platform or contact us directly.
This blog from the Health Systems Governance Collaborative is part of a curated blog series from the UHC2030 Health Systems Related Initiatives. The UHC2030 Related Initiatives promote collective action for stronger health systems that protect everyone. Find out more