“If you ask me whether we were prepared for this pandemic, I say that, obviously, we were not. If the question is whether we should be prepared for the next pandemics, I clearly say yes. We heard a lot of talk about the resilience and strengthening of healthcare systems, but we must turn speeches into actions.” This was one of the statements made by Carissa Etienne, director of the Pan American Health Organization (PAHO), last Friday (April 30), in her presentation at the Advanced Seminars on Global Health and Health Diplomacy, organized by Fiocruz Global Health Center (CRIS). The event discussed the future of Healthcare Systems in Latin America and the Caribbean, the United States, Africa and Europe in the post-pandemic of COVID-19. To this end, the seminar was also attended by Jeffrey Sachs, director of the Center for Sustainable Development at Columbia University; Paulo Ivo Garrido, former Minister of Health of Mozambique; and Paulo Ferrinho, full professor at Universidade Nova de Lisboa.
One of the premises of the event was presented at the beginning by Jeffrey Sachs: “We do not have a single global experience about the pandemic.” The responses of each region and country have been diverse and we can see how some countries have succeeded in controlling the pandemic and others have not. Therefore, it is necessary to assess what has gone right and wrong in each experience so that we can plan actions enabling to strengthen the different healthcare systems on a global level and that they are able to offer healthcare to citizens equitably and still respond to crises yet to come.
Jeffrey Sachs' assessment is that “the United States completely failed to curb the pandemic.” For the researcher, the country's response, as it happened in Brazil, was markedly politicized. Trump's leadership mistakenly believed that the problem would be solved by letting the virus spread. The U.S. population is in a high degree of polarization and that has impacted healthcare policies. “The USA remains a federal country, with many inequalities between states. We are experiencing a deeply divided society, with high wealth inequality, and there is still a partisan polarization in which Democrats want the vaccine and Republicans do not. This is the scenario we are stuck in,” he said.
For Sachs, since the arrival of the Joe Biden administration, but mainly with the increase in vaccination rates, the U.S. scenario has improved rapidly. Currently, about 30% of the population has been vaccinated and there is clearly an inflection point in the pandemic. However, it is a provisional scenario due to the new variants. If the whole world does not increase its vaccination rates and such mutations are not controlled, the U.S. population, even if vaccinated, remains at risk. In this regard, Sachs emphasizes the international character of the pandemic and that the global response requires the functioning of multilateral organisms, which had not been happening properly in part due to the withdrawal of the United States from the World Health Organization (WHO).
Weaknesses in African Healthcare Systems
Former Minister of Health of Mozambique, Paulo Ivo Garrido said that Africa's healthcare systems could be summed up in one word: fragility. He clarified the definition and elements that, for WHO, make up a Healthcare System, emphasizing which are the weaknesses that have been most latent in Africa due to the pandemic. “Healthcare System is a set of institutions, people and actions whose main purpose is the promotion, restoration and maintenance of individual and collective health. Six elements make up a Healthcare System: leadership and governance, human resources, funding, information systems, products and technology, and the provision of healthcare services,” he said.
For Garrido, the fragility of African healthcare systems is expressed in many ways and in virtually all the components mentioned. In the leadership, there are chiefs of state denying the disease and its methods of prevention; in human resources, there is shortage, precariousness, and exploitation of the professionals' work; funding is lacking; and products and technologies are scarce and outdated. According to the former minister, COVID-19 has caused a similar response in almost all countries in Africa. “Regular activities have been interrupted to focus on COVID-19, which meant the suspension of medical appointments, surgical interventions, and health promotion activities, among others.”
The changes that Garrido proposes follow two pillars: the first is the recognition by African governments that health is a citizen's right and duty of the state. The second pillar is about strengthening healthcare systems, considering its six components and reflecting on different political instances. “I propose that each African country draw up a plan to strengthen its Healthcare Systems. Lastly, the ex-minister admits that perhaps his suggestions seem to be utopian, but he quotes Mandela saying “It always seems impossible, until it’s done”.
Representing the region of the Americas, Carissa Etienne emphasized the need for strong political leadership and continued investment to overcome the public health crisis that goes beyond COVID-19. For PAHO's director, the changes that we must accomplish in the post-pandemic are very close to the changes that we should have accomplished before the pandemic, as they address structural issues that must guarantee access to health for citizens. Strong healthcare systems are more resilient and able to face crises like the one we are experiencing; we must not wait for a next pandemic to realize that we must fight inequality and address the gaps in healthcare systems.
“COVID-19 was not the first disease to hit our region and it will not be the last”, says Etienne, indicating some of the measures that must be taken. For the Dominican physician, “we need to fight inequalities in healthcare systems and insist on public funding of health care. Recognizing 6% of GDP in public funding and that 30% be invested in primary health care. We must work on innovation. In terms of vaccine and other inputs, there is no reason why the Caribbean and the Latin American region should not be self-sufficient and a source for the world,” said PAHO's Director, stressing the need to work in international cooperation, looking at the capabilities of each country.
Ettiene warns that the tendency, when recovering from COVID-19, is for states to cut investments in healthcare. It would be a monumental mistake, as the necessary changes include maintaining investments. According to the physician, the cost pays off much more than inaction. "COVID-19 has shown that a healthy economy depends on healthy people, and when someone falls behind, we are all at higher risk." PAHO's director reiterated the essential need to invest in primary care to move towards stronger, more resilient, and equitable systems. “Health is not a privilege, it is a right. This is a song we have been singing in the region for a long time,” he said.
Challenges for a European Health Union
In his presentation, Professor Paulo Ferrinho drew attention to the history of the formation of a European Healthcare System that came to enable the creation of a European Health Union, an institution that has a great opportunity to be strengthened and developed in the COVID-19 pandemic. The researcher points out that, before the pandemic, there was limited action by the European Commission on health issues, the member states having a supplementary role. Such limited capabilities explain to some extent the European Union's lack of adequate response at the onset of the pandemic. It has created a vicious cycle of national responses that has paralyzed regional coordination.
However, the Commission responded in March 2020 with a Road Map to harmonize lockdown measures in member states, creating a backup of essential equipment, defining specific health policies and approving the EU4Health 2020-2021 program to strengthen the European Health Union. The institution's main role is to be prepared to respond in times of health crises with actions such as strengthening the pharmaceutical industry, reinforcing the bloc's resilience, and coordinating in the face of possible cross-border threats.
Ferrinho explained that the Commission's financial response was robust, involving a € 540 million package to support the companies and workers most affected by COVID-19. Nevertheless, funding was considered insufficient. It also suggests that there has been a deficiency in Information Systems, which must be adjusted before the next pandemic. The professor concluded that there is a strong commitment to move towards strengthening a European Health Union, but that the success of this commitment depends on the advancement of four essential blocks: leadership and governance, funding, medical products and technology, and service provision.