As the world enters the third year of the COVID-19 pandemic, an increasing number of important efforts are underway to strengthen global health security.  However, it is vital that, while strengthening our global health architecture, we do not lose sight of the fundamental role played by national level health systems in tackling global health threats.

Throughout this and previous pandemics, the strength of countries’ national health systems has been a critical success factor against pathogens. For example, even many countries with well-organised, well-financed and well-staffed health systems suffered throughout COVID-19. Viewed through these lenses, global health security may exist only as the sum total of the performance of all national health systems of all countries, rather than as a standalone and separate entity.

Since the onset of the pandemic, we have seen a plethora of new institutions and new ideas for improving global health governance. These include the Access to COVID-19 Tools (ACT) Accelerator and the COVAX Facility in April 2020, the Independent Panel on Pandemic Preparedness and Response proposal in May 2021 for a Global Health Threats Council and the World Health Assembly (WHA) agreement in December 2021 to proceed with the negotiation and drafting of a new international instrument to strengthen pandemic prevention, preparedness and response.

It is hoped that these new international institutions and platforms will support better pandemic governance and financing at the global level. However, although a strong global focus is essential for ensuring equitable distribution of those goods that are necessary for fighting COVID-19 and future pandemics, national efforts must be equally prioritised. 

In other words, global leaders must resist two great temptations: the desire to build new institutions instead of strengthening existing ones such as the WHO and the International Health Regulations, and the tendency to ‘securitize’ health at the global level instead of implementing strong public health measures at the national level.

Three functions to achieve resilient health systems

Global health security demands strong and resilient health systems that can prevent, detect and respond to infectious disease threats, wherever they occur in the world.  Therefore, we propose a new understanding that approaches this goal through the lens of three interlocking functions at the national level. 

The first key function is building resilient national healthcare systems. It is critical that they have built-in surge capacity (including for primary healthcare) to manage patients who have been infected and require care, while at the same time continuing and sustaining routine health services for those who have not been affected.  In addition to deaths from infection during the COVID-19 pandemic, there have been an excess of deaths of non-infected persons over what would be expected, likely due to the fact that they were not able to access routine health care, especially that which required frequent attention.  The same occurred in West Africa during outbreaks of Ebola in 2014 – health facilities could not accommodate most of the patients with Ebola infection resulting in a high level of death from Ebola virus diseases, and also, the number of deaths from children who could not get care for malaria and other childhood diseases because of the lack of resilience in the health system was documented as being higher than the number of deaths from Ebola virus disease.   

The second key function is developing strong core public health capacities that meet the WHO’s International Health Regulations. Countries with early detection surveillance systems that identified outbreaks rapidly at the start of the pandemic, and those that had strong response mechanisms including outbreak responses – especially Singapore, Japan, and South Korea – showed the importance of strong public health core capacities to manage pandemics.  And rather than using blunt lockdowns of the entire economies, they were able to save lives by outbreak investigation, identification of sources of infection and then shutting them down with precision, rather than blunt lockdowns.    

Thirdly, countries need to invest in broader supportive environments that enable the health and wellbeing of their populations. Infection with SAR CoV2, as with many other viral and bacterial infections, resulted in more serious illness and death among the elderly and those with comorbidities such as diabetes, cardiac disease and obesity.  By using smart regulations and other healthy-lifestyle-enabling measures, governments can ensure populations are healthier and more resistant to serious illness after infection, decreasing morbidity and mortality in an outbreak and/or pandemic. Healthy populations also require adequate health financing, strong health literacy and health-seeking behaviours, and improving the social determinants of health, like education, housing and working conditions.

Synergistic approach as opposed to mutually exclusive strategies

This synergistic approach to universal health coverage, health security, and health promotion is necessary to prepare for future pandemics. Currently, many countries seem to assume that public health, universal health coverage and creating the enabling environment for healthy populations are mutually exclusive strategies.  This can be due to limited resources and/or donor funding pushing governments towards “false choices”. 

Such false distinctions are further enhanced by the “global nature” of global health security with accountability towards the international community, contrasted with the domestic nature of universal health coverage and health promotion, with accountability towards local voters, taxpayers and citizens. 

A strategy focused on the three interlocking functions provides countries with a middle way – an integrated approach that equally prioritises national and global health security. Each of the functions has a strong conceptual framework and large body of evidence to support its positive impact on global health security.  Each is closely aligned with well-established and highly-visible health frameworks. 

 It will take political and health leaders with courage, vision and ambition to rethink some of the many vertical (albeit well-meaning) global implementation and funding streams to ensure that they serve to strengthen these three functions and not bypass or weaken them. They will need understanding and support from the global health community.

If implemented correctly, the three interlocking functions would be mutually synergistic, with progress in one function accelerating or enhancing progress in another. Taken together, they represent a more balanced approach to global health security and reduce the risk of over-globalizing, over-engineering or over-securitizing health. By better linking these three functions within WHO, and within its guidelines for epidemic and pandemic preparedness, WHO technical support to countries could provide better preparedness and response capacity for the next major outbreak or pandemic.

Biographies

Professor David Heymann is professor of infectious disease epidemiology, London School of Hygiene & Tropical Medicine.

Professor Ilona Kickbusch is the Founder of the Global Health Centre at the Graduate Institute in Geneva.

Chikwe Ihekweazu is the WHO assistant Director General of health emergency intelligence, the former Director General of the Nigeria Centre for Disease Control (NCDC) and was previously the Acting Director of the West Africa Regional Centre for Disease Control.

Doctor Swee Kheng Khor is a physician specializing in health systems & policies and global health, focusing on south-east Asia.

Image Credits: Nigeria Centre for Disease Control , Flickr: Maxim Malov/CDC.