By Alex Ergo, PSI Senior Strategy and Health Financing Advisor and Pierre Moon, PSI Director
COVID-19 has exposed the fragility of health systems around the world, upended ways of planning and delivering healthcare and created suffering for individuals and communities on a scale unprecedented in recent times.
However, international Universal Health Coverage (UHC) Day reminds us there is a silver lining to this terrible cloud: the way individuals – and the many actors within health systems – have adapted has shed light on vital new pathways to accelerate progress toward UHC.
While many of these new pathways – private sector engagement, self-care and digital health – were already being shaped long before the pandemic, we can now see more clearly the opportunities these paths provide to building a new and stronger vision for health care.
COVID-19 Lesson 1: Yes, the private sector can be a trusted partner
Health systems strengthening efforts in the majority of low- and middle-income countries have long been dominated by supply-side considerations, focusing mostly on public sector service delivery. At the same time there has often been a bias towards ‘disease specific’ interventions. While there is a growing call for countries to invest more in primary healthcare (PHC), which is seen as paramount to the pursuit of UHC, and to redefine the key actors in the health system to include communities and a broader range of non-state actors, the private sector continues to be frequently overlooked as a critical part of the health system. This even though private healthcare providers, whether formal or informal, are often the first point of contact for people seeking health care, a reality especially true for people with very low incomes, for whom this may be the best or only option.
There is a myriad of reasons for this lack of integration of public and private sectors but the effect of this has been, in many countries, to leave the private sector largely unregulated, uncoordinated and unsupported. Not only does this have grave consequences for people’s health, it also fails to leverage the substantial resources already invested by the private sector and have them contribute to the health system’s goals.
The current pandemic has forced many governments to revisit their position with respect to the role of the private sector. With the rapid surge in the number of COVID-19 cases, ministries of health (MOHs) around the globe have had to look beyond the public health service delivery system and start engaging the private health sector, which in many countries has proven to be instrumental in the national COVID-19 response. Where the private sector is largely unregulated, it is critical for MOH to strengthen its stewardship role to ensure that private health sector activities are aligned with national response efforts. The WHO guidance around governance of mixed health systems, which was drafted prior to the pandemic, could not have been more timely.
COVID-19 Lesson 2: Yes, assisted self-care is a critical layer of the health system
The way individuals in many countries have adjusted to a new reality under COVID-19 points to a second challenge and opportunity that the ongoing pandemic has illuminated: while the pandemic has caused significant disruptions to the supply of essential health services, individuals have demonstrated a far greater ability to manage their health and healthcare than was previously assumed.
COVID-19 has shown that individuals, when given the right amount of tailored – i.e., insights-driven – support by ‘the health system’, can do so much more to manage their health and healthcare than the architects of health systems ever once thought possible. And nowhere is this more apparent than in the rapid advance of self-care, whereby interventions or information that were previously controlled and given by a clinical provider can now be managed by the individuals themselves, who become far more involved in, and in control of their own healthcare. Yet, current work around assisted self-care still tends to be largely focused on specific health areas, such as Sexual and Reproductive Health or HIV. While these are vital starting points to accelerate self-care in critical areas of healthcare, what COVID-19 has taught us – e.g., through innovations around symptom checking and triaging – is that assisted self-care can and should be further developed to more holistically respond to the individual’s health needs, and that it should be better integrated as a critical layer of a resilient and responsive health system. Already in June 2020 the WHO adapted its guidance for essential health services during the pandemic and recommended health systems use available technologies and regulations to facilitate the shift of clinical encounters to digital platforms and support self-care interventions where appropriate. Covid-19 has created a sense of urgency among MOHs to formalize support for self-care. The ministries in both Uganda and Nigeria, for example, are finalizing national self-care guidelines. Meanwhile, new public and private initiatives continue to emerge to facilitate an approach to self-care that promotes quality, equity and access.
COVID-19 Lesson 3: Yes, digital technology can accelerate efforts to build strong mixed health systems
Digital health solutions targeting individuals, healthcare providers or health systems have been around for some time. Yet, while such solutions may provide new and more efficient ways of planning and delivering healthcare, at least three fundamental challenges prevent a large proportion of them from increasing access to quality, equitable healthcare at scale. A first challenge is the fragmentation. Often developed as part of donor-funded, time-limited projects, many digital solutions are relatively narrow in scope (they tend to focus on one specific health area, such as maternal health or TB), short-lived (their use tends to end with the project) and duplicative. The ability for key national stakeholders to access the data such digital health solutions provide is also often constrained. A second challenge is the tendency to start with the solution rather than the problem, which results in solutions that do not fully address relevant consumer needs, nor build on their existing digital capacities and habits. Finally, many digital solutions fail to acknowledge the digital divide, i.e., the gap between those with regular, effective access to digital technologies and those without, which risks exacerbating health inequities.
Movements are under way to address these challenges, and these movements have gained impetus with the COVID-19 pandemic. Rockefeller Foundation’s Precision Public Health initiative aims to leverage data and analytic tools to accelerate progress on the world’s greatest public health challenges. Digital Square brings partners together to improve how the global community designs, uses, and pays for digital health tools and approaches, to reduce the disorganization and fragmentation. A number of development partners, from USAID to UNICEF, are also increasingly supportive of ‘market-based solutions’ to digital health, so as to increase the potential of such investments lasting beyond the lifetime of one initiative.
COVID-19, and more particularly the social distancing imposed to prevent its spread, has accentuated the important role that digital technology can play in connecting, or ‘wiring’ the different actors in the health system and transforming the delivery of PHC. The pandemic has accelerated the uptake of digital solutions in areas such as assisted self-care, telemedicine, digital signposting (i.e., directing the individual to the product or service she needs on-demand through her mobile phone) and e-pharmacy (where medicines and health commodities are prescribed or ordered online and delivered to the doorstep of the patient). It will be important, and yet the challenge for this generation, to nurture forces striving for a joined up health systems approach to digital health, while recognizing the vitality of allowing innovation to flourish and consumers to have choice.
COVID-19 Main Lesson: the whole is greater than the sum of its parts
In the previous sections, we have discussed three important lessons that COVID-19 has taught us so far:
- Lesson 1: Yes, the private sector can be a trusted partner
- Lesson 2: Yes, assisted self-care is a critical layer of the health system
- Lesson 3: Yes, digital technology can accelerate efforts to build strong mixed health systems
Of themselves, each of these efforts can potentially accelerate progress toward UHC. But, if we combine those three lessons, we can also create synergies that open up additional new pathways towards UHC, pathways that put the consumer at the center of UHC, as depicted in Figure 1.
By strengthening their stewardship role, by considering consumer and systems insights and by developing a robust digital strategy, MOHs are better equipped to actively engage the private sector and build more resilient and responsive mixed health systems that deliver quality PHC, starting with assisted self-care as a key tier of the system.
Digital technology increasingly becomes the glue that helps connect the different actors – both public and private, and from self-care all the way to secondary care facilities –bringing essential health services and products closer to the consumer and helping people seamlessly navigate that system to receive affordable and quality health services as and when needed.
Granted, this vision of a ‘wired’ ecosystem promoting strong mixed health systems including self-care and harnessing digital technologies in support of UHC has many pitfalls and obstacles ahead, not least that health systems are context and culture specific and as such there will never be a one-size-fits-all approach to solutions. However, just as the WHO Building Blocks once emerged as the solution to organizing stronger health systems, so this moment invites us all to think of ways we can reimagine healthcare and health systems. Strong mixed health systems that embrace self-care and digital health are going to be critical pathways to UHC.
