Opinion: We need a bolder, more equitable approach to public health

Health workers at work in Beledweyne, Somalia. Photo by: UNSOM Somalia

The millions killed and economies damaged by COVID-19 weren’t inevitable; they were caused by dangerous gaps and a lack of investment in our health systems. For the past 15 months, countries have relied on short-term solutions. That may be the best we can do in a crisis, but it’s not good enough for a secure, healthy future.

COVID-19 isn’t a Brazil, India, China, or U.S. crisis; it is everyone’s crisis in this interconnected world. We need a bolder and more equitable approach to public health in which everyone, everywhere, is protected. We cannot simply place a tarp over our collapsed roof and plan to build back to where we were before the pandemic ravaged our home. The structure itself is so unsound that the next storm could knock it over again. We must lay a new, more solid foundation and build from there.

As we look toward recovery, a part of that foundation must be the recognition that health is woven into all aspects of our policies and our societies. Whether the issue is air quality, transport, food, tobacco, drug use, or infectious disease, we have to think more holistically about the interconnections that form the building blocks of health.

To this end, we call for five areas of focus to rebuild our health systems:

1. Increase global solidarity

COVID-19 has exposed inequities within and among cities and countries and has shown how existing vulnerabilities are compounded in a crisis. While there have been some outstanding acts of global cooperation and compassion, self-interest and nationalism have also abounded — as when countries competed for scarce ventilators and protective gear in the early days of the pandemic.

World Health Organization Director-General Tedros Adhanom Ghebreyesus recently called vaccine equity “the challenge of our time,” and it’s a challenge that we are failing. More than 1.4 billion doses have been administered worldwide, but a third of all vaccinations have been in places that cumulatively contain only 10.4% of the world’s population.

This glaring inequity has multiple, interconnected causes. One is the failure of the COVAX initiative to deliver on its goal of equitable access to vaccines. Other causes include the afterthought of patent waivers, competition among countries for vaccine supplies, and entrenched, systemic disparities in the global public health system.

This unequal, unethical access to vaccines will prevent us from emerging from this pandemic anytime soon — and is perhaps the best and clearest example right now of why we need to create more global solidarity for health.

2. Build new and improved health infrastructure

Unlike roads, bridges, and electric grids, public health infrastructure is largely invisible — but it’s equally critical. Investing in health infrastructure is the only way to prevent a small problem from becoming a crisis.

Yes, this means new hospitals and health centers in rural areas and refurbishing deteriorating buildings, but it also means going beyond bricks and mortar. We must address the supply chain issues for medications and materials, transportation, access to electricity and clean water, and access to equipment while weighing the considerable short-term costs of strengthening infrastructure against the long-term costs of inaction.

Well-resourced surveillance and data systems are also essential. We have seen during the COVID-19 pandemic how important it is for governments to track the numbers of new cases, hospitalizations, and longer-term outcomes such as mortality to inform their response strategies. Building data systems begins with civil registration and vital statistics systems that record births and deaths completely — and with governments trained to analyze and use data to inform action and policy.

We also must recognize that the health care system is much more than doctors, nurses, clinics, and hospitals. We must build up the public health system, which comprises a much broader set of human resources and infrastructure, such as community health workers, epidemiologists, communication channels, and supply systems.

3. Solve the dire health worker shortage

Even the best infrastructure is useless without enough trained health workers. The health workforce was inadequate before the pandemic and has been further taxed as a result of it. WHO projects a shortfall of 18 million health workers by 2030.

This is largely due to a lack of skilled workers. Chronic underinvestment in the education and training of health workers in some countries and the mismatch between education and population needs are contributing to continuous shortages. These are compounded by difficulties in deploying health workers to rural, remote, and underserved areas and giving incentives for them to stay in those places where the need is greatest.

Global partnership and collaboration will be required to close the gap and provide long-term, meaningful investments in the health workforce — which means not only training more doctors, nurses, and other professionals but also giving them the pay and protections that will encourage them to stay.

4. Better understand and address the commercial determinants of health

People’s behaviors, such as what they eat and drink, are driven not just by individual preferences but also by the social and economic context in which they live. The inundation of marketing by companies that profit from unhealthy products — such as tobacco, alcohol, and ultra-processed foods — is one of the most powerful drivers of poor health.

Yet too often, governments are unduly influenced by industry and are actively subsidizing or not sufficiently regulating or taxing products that harm health, reduce productivity, and increase health care costs. At the same time, governments miss opportunities to incentivize the products that produce health actively.

Governments must make policies that put people ahead of the profits of entrenched industries that have nearly unfettered lobbying power and influence. WHO’s Framework of Engagement with Non-State Actors already addresses “undue influence,” and it should be strengthened to restrict the power of unhealthy commodity industries on global health policymaking.

We need a bolder and more equitable approach to public health in which everyone, everywhere, is protected.

5. Make cities healthier

Although many cities have been hard hit by the pandemic, they have also led the way in measures to slow the spread. We know that access to health care services is not the greatest determinant of health — far more important are access to safe housing, transport, water, electricity, and quality early education and social cohesion. As cities grow and as climate changes force more people into cities, we need to erase decades of inequitable access to the fundamentals of a healthy life.

Making cities healthier calls for cooperation and action across multiple sectors, not just public health. Health is woven across society, and leaders must recognize that their transport, education, housing, planning, and other departments have a role in promoting health.

In places where national or regional governments are slow to change, cities can lead the way with forward-thinking policies to address social and commercial determinants of health and systemic injustices — everything from affordable housing to healthy school food environments to safe, sustainable mobility.

Economic growth and development depend on a healthy population. The returns on investment in health are estimated to be 9 to 1, and each extra year of life expectancy has been shown to raise gross domestic product per capita by about 4%. Investing in health and healthy environments creates a virtuous circle: Countries with strong health infrastructures naturally generate more political will and commitment to support interventions around health crises when they emerge.

We’re at a defining moment in public health. Our post-COVID-19 future relies on the choices we make today. Robust, evidence-based investments in health in recent decades could have saved the world from much heartache this past year, and it can help prevent history from repeating itself in the years to come.

Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildBackHealth.

About the author

  • José Luis Castro

    José Luis Castro is president and CEO at Vital Strategies, where he has led a rapid expansion of its portfolio and worked with governments to tackle the world’s leading killers, primarily in low- and middle-income countries. The organization now reaches into 73 countries and has touched the lives of more than 2 billion people.