Investing in universal health systems aimed at Covid-19 and beyond

Challenge

The Constitution of the World Health Organization (WHO 2006) states: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” With the international community still tackling the COVID-19 pandemic, the issue of ensuring equitable access to quality health care is more relevant than ever before, and poses a great challenge to the G20, given that most countries have historically underinvested in health systems.

The COVID-19 pandemic has seriously tested the capacity of health systems worldwide and their resilience to high-impact shocks; moreover, the pandemic has led to high rates of unemployment, especially among informal workers. This demonstrates the importance of delivering social protection and essential public services for all. The universal health system (UHS) is a multi-dimensional concept, operationalized in terms of universal health coverage (UHC), universal financial protection, and universal access to quality health care. It is anchored on the premise that the provision of health care is a legal obligation for governments, grounded in international human rights laws. Hence, domestic regulations and political frameworks mandate the national government to deploy public resources to ensure health care for all (Rottingen et al. 2014), while “compelling the international community to support poor nations in implementing this right” (Abiiro and De Allegri 2015, 1).

The Extraordinary G20 Leaders’ Summit Statement (G20 Saudi Arabia 2020a, 1) on COVID-19 committed “to take all necessary health measures and seek to ensure adequate financing to contain the pandemic and protect people, especially the most vulnerable.” The pandemic has turned the G20 authorities’ attention to the importance of investing in health systems, as evident from the G20 Health Ministers Meeting for coordinating efforts to combat COVID-19. The focus of these efforts is not only preparing for future emerging diseases and minimizing the risk of economic crises caused by inadequate health systems, but also guaranteeing financial protection against the catastrophic and impoverishing out-of-pocket expenditure involved in receiving treatment.

Mitigating health access inequities
The term health inequalities may be defined as differences in the status of people’s health, but can also be used to refer to differences in the opportunity to maintain healthy lives (social determinants of health) and access health care. Most countries have underinvested in their health care systems. A comprehensive UHS can better respond to those inequalities and to external shocks, enhancing resilience to disasters and stimulating a transparent, responsible, inclusive, and sustainable framework (Ayadi and Sessa 2020). A UHS includes a health care network based on hierarchy and privileges an integral, primary care level approach in order to reach the most vulnerable; an epidemiological surveillance network, with robust national institutes of health for diagnosis; and biological research to produce and share information nationally and globally, and to provide scientific evidence to support reliable public policies. These structures are necessary to develop common monitoring mechanisms, encourage access to new technologies at the primary level, and harness innovation at all levels of care.

Financing universal health systems
Weak and fragmented health systems hinder access to quality health care as well as the systems’ capacity to face the COVID-19 pandemic or future pandemics. The longer this situation persists, the more disruptive the changes in health financing will be.

In 2015, the Addis Ababa Action Agenda (United Nations 2015) stated that investing in sustainable and resilient infrastructure, including health, was essential to achieve the sustainable development goals (SDGs). “Cohesive […] integrated national financing” (United Nations 2015), together with international contribution, should be at the core of national infrastructure efforts, but this remains a challenge for the G20.

The COVID-19 pandemic has increased the importance of health financing. On March 26, 2020, the G20 recognized the need to spend more on the health sector (G20 Saudi Arabia 2020a) and in April, the G20 Ministers of Health Meeting “recognized that the COVID-19 pandemic highlighted systemic weaknesses in health systems” (G20 Saudi Arabia 2020b, 1). They also mentioned the importance of supporting more vulnerable countries, especially in Africa.

The UHS calls for more investment from the domestic public and private sectors (United Nations 2015). G20 countries must balance the changes in financing patterns between public and private financing. These challenges demonstrate the importance of establishing partnerships to deliver social protection and essential public services for all to support sustainable development (Rottingen et al. 2014).

Coordinated international aid and cooperation for health
The COVID-19 pandemic has shown how essential it is to support collaboration, coordination, and communication within the national as well as international community. Recognizing the central role of the WHO in this coordination, including its role in supporting the implementation of the International Health Regulations, is a key element of the G20 Statement and the G20 Ministers of Health Declaration.

Globally coordinated responses and solidarity are necessary in tackling the COVID-19 pandemic until an effective treatment and/or a vaccine is available and accessible. The WHO may be a key enabler for strengthening health systems globally; the G20 must empower the WHO to be more effective and coordinate global health issues and pandemics. The G20 must advocate for strong and resilient health systems and health institutions through solidarity, collaboration, and contribution between governments and international organizations.

Proposal

Universal health systems to ensure universal health coverage as a right to mitigate inequities in health care access

Privileging integral primary care
To reduce inequalities, the G20 members should advocate health as a human right; they must transmute this into the right to access, covered under a universal health system. Such a system must include a basic level of primary health care (PHC) as an essential step to achieve universal health coverage and mitigate inequalities in access to health systems.

1. Reinforcing PHC within health care systems. Adapting public health care models, compared to individual models of care, only requires a change in approach. This is relevant at all times, and not just during pandemics. A comprehensive approach to PHC involves identifying the social determinants of health and the components of health promotion, and ensuring equity in the attention paid to health care. PHC is crucial for guaranteeing access to health care and synergistically meeting the SDGs (Giovanella 2019).

2. Reaching the most vulnerable population groups through PHC. In previous years, the G20 has committed to focusing on policies to support aging populations, who are also the group most affected by COVID-19. The pandemic has also revealed the vulnerability of groups beyond the aged population, and comprehensive PHC models are, therefore, important to gain access to the most vulnerable populations

3. Investing in developing, producing, and distributing new technological tools to improve PHC. Modern medical supply and artificial intelligence (AI) models based on social and health care data are essential for public health interventions at the primary level and are most important during outbreaks.

Prioritizing the national institutes of health for more resilient health systems
The G20 should support and advocate for strong national public institutes of health (NIHs) within the universal health care system and collaborate to develop the global public health care capacity. These institutions are essential for disease diagnosis and health research, providing the necessary scientific evidence for developing strong, resilient, and sustainable health systems and health-related public policies. The COVID-19 pandemic has highlighted the importance of these institutes in the areas of genomic research, immunological responses, clinical trials, and epidemiological tracing, as well as in supporting health and epidemiological surveillance.

Future G20 investment in health projects or initiatives will need to consider the importance of investing in public health institutes to strengthen decision-making processes by supporting improvements in health-related data collection and health research. NIHs are important for tracing indicators and monitoring efforts as well as for adopting, as needed, a broader range of forward-looking and interlinked indicators on universal access to health care for sustainable development.

G20 members who have strong health care systems must invest in the development of national institutes of public health as part of health care systems in order to mitigate health inequalities within and among countries.

Encouraging access to new technologies and harnessing innovation
Technological innovations may be an important factor in creating strong health care systems and establishing UHC, especially in low- and middle-income countries. The G20 governments can support measures to ensure equitable access by leveraging digital technologies (G20 Saudi Arabia 2020a). The COVID-19 pandemic has demonstrated the importance of innovation and new technologies at different levels of health care. Smartphone-based software in PHC shows how enabling epidemiological surveillance and data collection as well as a digital dialogue with citizens and communities through technology is key during epidemics.

It is necessary to call on the G20 to invest in new technologies and innovation in areas related to health as well as clean energy supplies for digital communication. This can enable countries to leapfrog previous steps to increase access to health information and care and accelerate progress toward UHC. This will require the G20 to encourage new forms of collaboration between the public and private sectors, and support public-private partnerships for meeting health care needs at scale.

In its Statement on COVID-19, the G20 committed to “strengthen national, regional, and global capacities to respond to potential infectious disease outbreaks by substantially increasing our epidemic preparedness spending” (G20 Saudi Arabia 2020a).

Some ways in which the G20 can maximize its spending are:

a. Oversee coordinated actions among governments to remove, both during pandemics and in other times, fiscal barriers to medical, pharmaceutical, and digital products and provide inputs for the creation and development of local industries, especially in poorer countries.
b. Establish support subsidies for equal access to clean energy sources and high-speed Internet technologies.
c. Encourage the use of new digital technologies (hardware) for health surveillance that could also follow up on population groups based on their risk level, and link information on symptoms to advise on possible diagnosis and treatments.
d. Develop artificial intelligence (AI) model(s) (software) based on social and health care data that would in turn reduce the burden on health care systems in typical times as well as pandemics. Such models can monitor population movement and track exposure to diseases but must ensure privacy and information security.

Financing universal health systems
The COVID-19 pandemic has demonstrated how the lack of effective and trusted health services increases the risk of major shocks. After the pandemic, more than ever, health systems will need interconnected changes. Health system financing must consider: 1) the increasing demand for health services and the capacity to pay for them, 2) population aging, 3) double and/or triple burden of diseases (chronic, infectious, and regular injuries), and 4) new medical technologies and communication tools. These elements are increasing expectations for health care among countries; considering them would ensure that equity in access is preserved, especially in population groups with high risk. Those issues were part of the health sector agenda before the pandemic and are now at the core of discussions at a time of fiscal stagnation and changes in the labor models.

Access to health services will make a difference in the future political scenario for emerging economies. G20 countries should encourage innovative approaches for coping with rapidly increasing demand and/or challenges associated with fiscal stagnation (Bloom et al. 2019), considering the following points:

1. When benefitting from debt moratorium, asking countries to invest in health care systems and social protection, mainly for vulnerable populations.

2. Strengthening public policies, regulatory frameworks, and finance at all levels, and advocating for new financing sources for health systems, such as:

a. Financing health systems by decoupling expenditure within national GDPs (around 7%) and mobilizing domestic private resources to reliably finance necessary health care.
b. Financing health services by social value and cost-effective best buys.
c. Ensuring fiscal discipline in resource allocation and spending with the aim of long-term sustainability.

3. Advocating for the creation of a Global Crisis Management and Recovery Fund to mobilize development and humanitarian financing. This will ensure that interventions on health care systems support and new medical technologies during times of crisis strengthen capacity building and technical assistance, especially to at-risk communities (Abiiro and De Allegri 2015).

Coordinating international aid and cooperation for health
The G20 highlights multilateralism as a key condition for globally sustainable development and cooperation. At this moment, when countries may take different measures to face the pandemic, the G20, together with the Organisation for Economic Cooperation and Development (OECD) and European Union, must support the WHO’s mandate of coordinating the international fight against the pandemic and commit to strengthen health care systems globally, including through supporting the full implementation of the WHO International Health Regulations.

The G20 has an important role to play in the health care sector as its member nations’ economies represent 85% of the world GDP, and may exercise this role both with the international aid community (OECD) and UN organizations for more efficient cooperation among countries to improve global health care, aiming at the SDGs and the 2030 Agenda. Given its essential role within the international cooperation arena and aiming at a sustainable UHC, the G20 should consider:

1. Supporting not only specific countries, but also global, regional, and sub-regional health institutions, in improving bilateral and multilateral technical and technological cooperation.

2. Supporting and financing a UN-based Global Action Plan on cooperation for UHS implementation.

3. Advocating for partnerships between countries and between public and private health sectors to create a shared supply of beds, professionals, equipment, and pharmaceutical inputs to ensure equitable and adequate universal health systems

4. Supporting coordinated international actions for establishing the UHS, aiming for the development of common UHC monitoring mechanisms, using mutual learning and best practices platforms for UHC at local, regional, and global levels.

5. Supporting successful local and regional initiatives or experiences in UHS implementation exchange. There is significant evidence that a mutual learning approach minimizes risk to countries, and paves the way to supportive and collaborative international cooperation.

Acknowledgement
We appreciate the support of Aljawhara Al Quayid and Jitendra Roychoudhury, who were our tireless points of contact for the Saudi Arabia G20.

Disclaimer
This policy brief was developed and written by the authors and has undergone a peer review process. The views and opinions expressed in this policy brief are those of the authors and do not necessarily reflect the official policy or position of the authors’ organizations or the T20 Secretariat.

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