During the 2014-2016 Ebola outbreak in West Africa, donors, affected countries, and health institutions pointed to the importance of building strong health systems that could both respond to emergencies and sustain affordable and accessible health care after the end of the outbreak.
As the COVID-19 pandemic continues to strain health systems around the world, the top priority has rightly been the immediate emergency response — but these efforts do not exist in a vacuum, and near-term recovery is not the only thing at stake. Countries’ reactions to COVID-19 should accelerate health systems interventions that not only help them recover from the pandemic, but also help ensure universal health coverage, or UHC, in the future.
Lessons from the Philippines
The Philippines has managed to cap off decades of health progress by writing the right to UHC into law; enrolling all citizens with the national Philippine Health Insurance Corp., or PhilHealth; and prescribing reforms to make UHC a reality. This national policy has anchored the health sector’s response to COVID-19 and enabled the country’s Department of Health to maintain its commitment to UHC amid the current crisis.
Prior to the pandemic, the United States Agency for International Development’s ReachHealth Project — in collaboration with the Philippines Health Department, PhilHealth, the World Health Organization, and other partners — helped develop national tools and trainings on UHC, while supporting local governments to roll out the policies and structures that would manage UHC implementation and financing.
At times, it could be tricky to move this work forward. Policies and interventions that tackle systems-level challenges are huge lifts for health officials and health facilities. For example, it could be hard to get a hospital director to attend a meeting on referral pathways when they have so many pressing matters on their hands.
COVID-19 has shed light on the systemic flaws within health care systems worldwide. This op-ed explores Rwanda’s response to the pandemic through the lens of UHC, sharing key lessons for other countries.
When COVID-19 added a complicated new set of diagnostics, treatments, and care protocols on top of the current health structure, these broader systems-level changes became increasingly urgent. USAID ReachHealth accelerated interventions around the country’s COVID-19 response that, by their very nature, also helped bring the country closer to UHC. They include:
• Institutionalizing a system to help health facilities prevent infection of patients and health workers, not only for COVID-19 but also for other infectious diseases.
• Supporting more health facilities to comply with Health Department certification and PhilHealth accreditation, giving people greater confidence in the quality of health services and ensuring facilities can be reimbursed by the national health insurance fund.
• Helping local governments access and maximize critical funding, including COVID-19 benefits packages, for local health facilities to remain fiscally viable and sustain health operations throughout the crisis.
COVID-19 has also shone a harsh light on long-standing health system inefficiencies and inequities, particularly in the provision of primary care services. USAID ReachHealth successfully advocated for family planning services to be categorized as essential health services during the pandemic. This paved the way for local government compliance and facilitated deliveries of family planning commodities to address stockouts during the pandemic.
Progressing toward UHC, even in an emergency
There is more that governments and the global health community can do to ensure the fight against COVID-19 translates into gains that will help all people access quality and affordable health care.
Strong political will is important — but national efforts must be supported by aligned policies. Namely, national health security and preparedness agendas must be aligned with UHC guidelines. WHO, USAID, and other development partners can offer technical assistance, helping countries apply international guidance and frameworks to national policies. Ministries of health can then prepare the health governance infrastructure needed to support these policies and frameworks, with involvement and buy-in from local stakeholders.
Anticipating the additional cost of COVID-19 — from prevention to diagnostics and treatment — and making this a standard part of the UHC package is also critical. People should not have to pay out of pocket, and health facilities must recover their costs so they can maintain the overall provision of services and quality of care.
Health officials must also get creative in considering how health systems changes evolve in the new normal. Digital health and telemedicine are opportunities to preserve the right to health, but we can go beyond that. In the Philippines, one strategy that has proven valuable during the pandemic is shifting more responsibilities and resources from tertiary hospitals to community health workers and primary health care providers, as well as leveraging private sector services.
Community health workers were able to maintain steady family planning services and provide accurate information on service availability and infection prevention and control, removing some of the burden from nurses and doctors working in the direct response. Such strategies could strengthen access and resiliency in the wake of the pandemic.
Lastly, the move toward UHC opens doors for cross-sector partnerships, which are also key to the pandemic response. Other sectors must be engaged as part of the solution — from the private sector for health workforce and supply chain solutions, to the banking sector for financial disbursements, to the education sector for sustained, quality learning.
Many aspects of the COVID-19 pandemic keep health experts up at night. For us, it is the question of how countries such as the Philippines can continue to make progress toward UHC when something as monumental as COVID-19 hits the health system like a ton of bricks.
Five years after the Ebola outbreak, its impact on health systems is not yet clear. In Guinea, researchers found that external support during the outbreak focused heavily on response and future epidemic preparedness and generally did not affect the affordability of essential health services. In Liberia, researchers concluded that while the outbreak did bring about some positive systems-level changes, further attention and investments are needed to build a truly resilient health system.
In five years, we want to look back at the COVID-19 pandemic and know that we went beyond talking about the importance of health for all during this crisis. We will want to see that COVID-19 was successfully mitigated as a health threat and that health systems emerged stronger and better equipped to provide health for all, including the most vulnerable.
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